The facility had a census of 37 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide Resident (R) 3, R14, and R36 or their representative, the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. This placed the resident at risk of uninformed decisions about their skilled services. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment but can make an 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 services. Review of the ABN form provided to R3 revealed the form lacked the estimated cost of continued service and R3 received the wrong form. R3 received the CMS-R-131 instead of CMS Form 10055. The resident's skilled services ended on 09/09/24. Review of the ABN form provided to R14 revealed the form lacked the estimated cost of continued service and R14 received the wrong form. R14 received CMS -R-131 instead of CMS Form 10055. The resident's skilled services ended on 01/24/25. Review of the ABN form provided to R36 revealed the form lacked the estimated cost of continued service and R36 received the wrong form. R36 received CMS -R-131 instead of CMS Form 10055. The resident's skilled services ended on 01/24/25. On 03/05/25 at 10:00 AM, Administrative Staff A verified the facility provided the CMS-R-131 form to R3, R14, or R36, and/or their representative, and failed to provide the 10055 with the estimated amount it would cost the resident if they wished to continue services. The facility's Advance Beneficiary Notices policy, dated September 2022, recorded residents were informed in advance when charges would occur to their bills. If the director of admissions or benefits coordinator believed (upon admission or during the resident's stay) that Medicare 9Part A of the fee for Service Medicare Program) would not pay for an otherwise covered skilled service(s), the resident (or representative) was notified in writing because the service(s) may not be covered and of the resident's potential liability of the non-covered service(s). If the facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) for the following triggering events: A) Initiation- In the situation in which the director of admissions or benefits coordinator believes Medicare will not pay for extended care items or services that a physician has ordered, A SNB ABN is issued to the beneficiary before those noncovered extended items or services are furnished to the beneficiary. B) Reduction- In the situation in which the facility proposes to reduce a beneficiary's extended care items or services because it is expected that Medicare will not pay for a subset of extended care items or services, or any items or services at the current level and/or frequency of care that a physician had ordered the SBF ABN is issued to the beneficiary before items or services to the beneficiary are reduced. C) Termination- In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it is expects Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before each extended care items or services are terminated. D) 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 R3, R14, and R36 or their representatives, the correct 10055 form which included an estimated cost of continued services when discharged from skilled care. This placed the residents at risk of uninformed decisions about their services and the continuation of their skilled services.

The facility identified a census of 37 residents. Based on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment. Findings included: - On 03/05/25 at 11:30 AM a review of staffing for background checks was completed for facility Staff. Upon request and review the facility was unable to provide evidence a criminal background check had been completed for Maintenance staff U, who had worked at the facility since 05/21/2020. On 03/05/25 at 11:35 AM, Administrative Staff A stated the business manager would obtain criminal background/record checks on all employees prior to the employee working at the facility. Administrative Staff A verified she could not find a criminal record check for Maintenance Staff U and the business office manager who was at the facility when he was initially hired no longer worked at the facility. Administrative Staff A verified Maintenance Staff U would be placed on suspension and not work in the building until they obtained a criminal background check. The facility's Background Screening Investigation dated March 2019 documented the facility conducts employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants for positions with direct access to residents(direct access employees). For purposes of the policy direct access employee means any individual who has access to a resident of a long-term care facility or provider through employment or through a contact and has duties that involve (or may involve) one-on-one contact with a resident of the facility or provider, as determined by the state for purposes of the national background check program. The director of personnel, conducts background checks, reference checks, and criminal conviction checks on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted. The facility failed to conduct a criminal background check as required for Maintenance Staff U prior to employment at the facility. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the Long Term Care Ombudsman (LTCO) for Resident (R) 8's and R4's facility-initiated discharge to the hospital. This deficient practice placed R8 and R4 at risk for impaired rights. Findings included: - R8's Electronic Medical Record (EMR) recorded diagnoses of emphysema (collection of pus in the pleural cavity related to bacterial pneumonia,) dementia (a progressive mental disorder characterized by failing memory and confusion), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pulmonary fibrosis (a lung disease that causes scarring of the lung tissue, making it stiff and thick), and narcolepsy (excessive uncontrolled daytime sleepiness). R8's 5 Day Scheduled Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded R8 was independent with most activities of daily living (ADL). The MDS recorded the resident received oxygen therapy. The Care Area Assessment (CAA), dated 07/23/24, recorded R8 required substantial assistance with bathing and shower transfers and was independent with bed mobility, transfers, and walking. R8's Care Plan, dated 01/24/25 recorded R8 had an ADL self-care performance deficit due to dementia and poor safety awareness. The care plan documented the resident was on continuous oxygen due to COPD with hypoxia (a medical condition where there is an inadequate supply of oxygen to the body tissue), but often removes the oxygen. The care plan documented staff would notify the physician of changes in behavior, altered mental status, disorientation, lethargy, dehydration, or infections. The Physician's Order, dated 03/25/24, directed the staff to provide the resident oxygen at five liters per nasal cannula due to hypoxia. The Physician Order, dated 02/25/24, directed the staff to administer Albuterol Sulfate (bronchodilator medication that relaxes and opens the air passages in your lungs) Nebulization solution (two and a half milligrams (mg)/ three milliliters (mL), one inhalation per nebulizer every two hours as needed for shortness of breath. The Physician Order, dated 02/22/25, directed staff to administer Budesonide (steroid medication that reduces inflammation in the lungs) suspension 0.25 mg/ two mL, two mL inhale orally per nebulizer every 12 hours as needed for shortness of breath. On 01/19/25 at 08:00 AM the Nurse's Notes documented R8 was observed in the bathroom with her oxygen above her nose, had a nonproductive cough, and increased shortness of breath. Staff reapplied the resident's oxygen and she was assisted back to bed. On 01/19/24 at 11:34 AM the Nurse's Notes documented R8 received an as-needed Albuterol breathing treatment at 11:04 AM and her lungs were clear with no further shortness of breath. The resident complained of pain in her back, with weakness and lethargy (a state of extreme tiredness, drowsiness, and lack of energy). R8's oxygen saturation was 94 (normal range is 95 percent -100 percent) percent on five liters of oxygen per nasal cannula. The resident was moaning/groaning with back pain and the resident had pain and discomfort with urination. The nurse notes documented staff administered Norco (Opioid pain medication) at 11:41 AM. On 01/19/25 at 12:34 PM the Nurse's Notes documented that staff notified the on-call provider and stated her change in condition and the physician ordered lab work and a Covid test. On 01/19/25 at 12:50 PM the Nurses Notes documented lab work was obtained and sent to the hospital and staff tested the resident for Covid and it was negative. On 01/1/9/25 at 02:06 PM the Nurses Notes documented a nurse received a call from the provider and stated the resident's [NAME] blood Count (measures the number of white blood cells in your blood, white blood cells are a part of the immune system that help fight off infections and other diseases) was 14 which was elevated and indicated the resident had an infection somewhere and showed signs of dehydration. The nurse's notes documented the provider had the facility send the resident to the hospital for further workup. On 01/19/25 at 03:04 PM, the resident was transported to the hospital via facility van. On 01/19/25 at 04:49 PM, the hospital called the facility to report the resident was being admitted for pneumonia (type of bacterial infection). R8's clinical record lacked documentation that staff notified the LTCO of the resident's discharge from the facility. On 03/04/25 at 02:30 PM, Administrative Staff A stated they did not have any notification to the Ombudsman regarding the resident's discharge to the hospital. Administrative Staff A stated she was unaware of the last time they sent a discharge from the facility to the Ombudsman and was not aware she needed to send that information to the LTCO. Administrative Staff A stated it was her understanding they were to notify the Ombudsman only if it was a facility-initiated discharge against the resident's wishes. The facility's Transfer or Discharge, Facility Initiated policy, dated October 2022, documented that once admitted to the facility, residents had the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification, orientation, and documentation as specified by this policy. Transfer and discharge include movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non-certified bed outside of the facility. Transfer and discharge did not refer to the movement of a resident to a bed within the same facility. When residents are sent emergently to an acute setting, such as a hospital, were permitted to return to the facility. Residents who were sent to the acute care settings for routine treatment/planned procedures are also allowed to return to the facility. The Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term (LTC) Ombudsman when practicable (e.g., in a monthly list of residents that includes all notices content requirements). The notice of discharge will be provided. The facility failed to notify the LTCO of R8's facility-initiated discharge to the hospital. This deficient practice placed the resident at risk for impaired rights. - R4's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), basal cell carcinoma (a type of skin cancer that originates in the basal cells, which are the deepest layer of the outer layer of the skin), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and retention of urine (a condition where a person is unable to completely empty their bladder). R4's Discharge Minimum Data Set (MDS) dated 12/12/24 documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R4's Entry MDS dated 12/16/24 documented a re-entry to the facility from a critical access hospital. R4's Discharge MDS dated 01/12/25 documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R4's Entry MDS dated 01/29/25 documented a re-entry to the facility from a critical access hospital. R4's Significant Change MDS dated 02/04/25 documented he had a Brief Interview for Mental Status (BIMS) score of five which indicated severely impaired cognition. R4 displayed verbal behaviors on one to three days during the look-back period. R4 required substantial to totally dependent on staff for his functional abilities and activities of daily living (ADL). R4 utilized a walker and a wheelchair to assist with his mobility. R4 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). R4's Cognition Care Area Assessment (CAA) dated 02/06/25 documented he had a potential for further mobility decline, falls, skin break-down, and pain related to muscle weakness, impaired mobility, difficulty walking, malaise, CHF, and Alzheimer's dementia. R4's Care Plan revised 02/18/25 directed staff that R4 wished to return home, however, he is here long-term due to progressive dementia and did not have 24-hour care at home. Staff were directed to establish a pre-discharge plan with R4's family, evaluate the progress, and revise the plan as needed. The facility failed to provide the required written notification of transfer to R28 and his representative for his facility-initiated discharges on 12/12/24 and 01/12/25 that included: the reason for the transfer; the effective date of transfer; the specific location of the transfer; an explanation of the right to appeal the transfer to the state; the name, address, and telephone number of the state entity which receives appeal requests; the name, address, and phone number of the representative of the office of the stated long-term care ombudsman; and the notice must be provided to the resident and resident's representative as soon as practicable. The facility failed to provide evidence that the long-term care ombudsman (LTCO) was notified of R4's facility-initiated transfers to the hospital on [DATE] and 01/12/25. On 03/04/25 at 07:58 AM, R4 sat at the dining table eating breakfast. R4 had his supplemental oxygen on. On 03/04/25 at 02:45 PM, Administrative Staff A stated she could not provide notification to the ombudsman it was their understanding the ombudsman was only notified if it was a facility-initiated discharge against a resident's wish. Administrative Staff A stated that the facility did not do any written notification of transfer as the family was notified by a phone call when a resident was sent out to the hospital. The Transfer or Discharge, Facility-Initiated policy revised October 2022 documented the notice of transfer or discharge (emergent or therapeutic leave) was given as soon as practicable. The notice of transfer was provided to the resident and representative as soon as practicable before the transfer and to the LTCO when practicable (in a monthly list of residents that included all notice content requirements). The facility failed to provide written notification of transfer to R4 or their representatives for their facility-initiated transfers. The facility failed to provide notification to the LTCO for R4. These deficient practices had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 8 and R4 with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R8's Electronic Medical Record (EMR) recorded diagnoses of emphysema (collection of pus in the pleural cavity related to bacterial pneumonia), dementia (a progressive mental disorder characterized by failing memory and confusion), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pulmonary fibrosis (a lung disease that causes scarring of the lung tissue, making it stiff and thick), and narcolepsy (excessive uncontrolled daytime sleepiness). R8's 5 Day Scheduled Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded R8 was independent with most activities of daily living (ADL). The MDS recorded the resident received oxygen therapy. The Care Area Assessment (CAA), dated 07/23/24, recorded R8 required substantial assistance with bathing and shower transfers and was independent with bed mobility, transfers, and walking. R8's Care Plan, dated 01/24/25 recorded R8 had an ADL self-care performance deficit due to dementia and poor safety awareness. The care plan documented the resident was on continuous oxygen due to COPD with hypoxia (a medical condition where there is an inadequate supply of oxygen to the body tissue), but often removed the oxygen. The care plan documented staff would notify the physician of changes in behavior, altered mental status, disorientation, lethargy, dehydration, or infections. The Physician's Order, dated 03/25/24, directed the staff to provide the resident oxygen at five liters per nasal cannula due to hypoxia. The Physician Order, dated 02/25/24, directed the staff to administer Albuterol Sulfate (bronchodilator medication that relaxes and opens the air passages in your lungs) Nebulization solution (two and a half milligrams (mg)/ three milliliters (ml), one inhalation per nebulizer every two hours as needed for shortness of breath. The Physician Order, dated 02/22/25, directed staff to administer Budesonide (steroid medication that reduces inflammation in the lungs) suspension 0.25 mg/ two milliliters, two ml inhale orally per nebulizer every 12 hours as needed for shortness of breath. On 01/19/25 at 08:00 AM the Nurses Notes documented R8 was observed in the bathroom with her oxygen above her nose and had a nonproductive cough and increased shortness of breath. Staff reapplied the resident's oxygen and she was assisted back to bed. On 01/19/24 at 11:34 AM the Nurse's Notes documented R8 received an as-needed Albuterol breathing treatment at 11:04 AM and her lungs were clear with no further shortness of breath. The resident complained of pain in her back, with weakness and lethargy (a state of extreme tiredness, drowsiness, and lack of energy), oxygen saturation was 94 (normal range is 95 percent -100 percent) percent on five liters of oxygen per nasal cannula. The resident was moaning/groaning with back pain and the resident had pain and discomfort with urination. The nurse notes documented staff administered Norco (pain medication) at 11:41 AM. On 01/19/25 at 12:50 PM, Nurses Notes documented staff notified the on-call provider and stated her change in condition and the physician ordered lab work and a Covid test. On 01/19/25 at 12:50 PM, the Nurses Notes documented lab work was obtained and sent to the hospital and staff tested the resident for Covid and it was negative. On 01/19/25 at 02:06 PM, Nurses Notes documented the nurse received a call from the provider and stated the resident's [NAME] blood Count (measures the number of white blood cells in your blood, white blood cells are a part of the immune system that help fight off infections and other diseases) was 14 which was elevated and indicated the resident had an infection somewhere and showed signs of dehydration. The nurse's notes documented the provider had the facility send the resident to the hospital for further workup. On 01/19/25 at 03:04 PM, Nurses Notes documented the resident was transported to the hospital via facility van. On 01/19/25 at 04:49 PM, Nurses Notes documented the hospital called the facility to report the resident was being admitted to the hospital for pneumonia (type of bacterial infection). R 8's clinical record revealed a copy of the bed hold policy dated 10/20/21 (date of admission) that had her resident representative signature. Administrative Staff A verified the resident's representative did sign the paper on admission however the facility was unable to provide written evidence upon request they had spoken with the representative to acknowledge her understanding of the facility bed hold policy at the time of the hospital admission 01/19 thru 01/24/25. On 03/04/25 at 02:03 PM, Administrative Nurse E verified the facility lacked evidence of a signed bed hold policy notice that had been verbally acknowledged, provided, or signed by the resident's representative when R8 was transferred and admitted to the hospital on [DATE]. The facility's Bed Hold policy dated 10/20/21 documented that privately paying residents would be charged the hospital reserve rate for their rooms during hospitalization or any other leave of absence from the facility until the day they are officially discharged from the facility. The reserve daily rate equals 67 percent of the daily rate of the room. Medicaid reimburses the facility for the first 10 days per hospitalization, during which time the resident's bed would be held for them. On the 11th day of hospitalization, the resident risked losing their bed at the facility. If the facility is not able to hold their bed after the 1oth day, and assuming the facility can still care for the resident successfully after the hospital event, the resident would have priority in returning to the facility as soon as an appropriate bed becomes available. Medicaid would allow 18 days of therapeutic leave a year, during which a resident's bed is held for them. This would include any stay outside the facility that is not medically necessary, such as a family visit or vacation. Residents and responsible parties would be reminded of the bed hold policy at the time of the resident's admission to the hospital or prior to a leave of absence. The facility failed to provide R8's representative with a copy of the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.- R4's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), basal cell carcinoma (a type of skin cancer that originates in the basal cells, which are the deepest layer of the outer layer of the skin), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and retention of urine (a condition where a person is unable to completely empty their bladder). R4's Discharge Minimum Data Set (MDS) dated 12/12/24 documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R4's Entry MDS dated 12/16/24 documented a re-entry to the facility from a critical access hospital. R4's Discharge MDS dated 01/12/25 documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R4's Entry MDS dated 01/12/25 documented a re-entry to the facility from a critical access hospital. R4's Significant Change MDS dated 02/04/25 documented he had a Brief Interview for Mental Status (BIMS) score of five which indicated severely impaired cognition. R4 displayed verbal behaviors on one to three days during the look-back period. R4 required substantial to totally dependent on staff for his functional abilities and activities of daily living (ADL). R4 utilized a walker and a wheelchair to assist with his mobility. R4 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). R4's Cognition Care Area Assessment (CAA) dated 02/06/25 documented he had a potential for further mobility decline, falls, skin breakdown, and pain related to muscle weakness, impaired mobility, difficulty walking, malaise, CHF, and Alzheimer's dementia. R4's Care Plan revised 02/18/25 directed staff that R4 wished to return home, however, he is here long-term due to progressive dementia and did not have 24-hour care at home. Staff were directed to establish a pre-discharge plan with R4's family, evaluate the progress, and revise the plan as needed. The facility failed to provide evidence a bed-hold was completed and signed by R4 or his representative upon R4's hospitalizations on 12/12/24 and 01/12/25. The facility failed to provide evidence that the long-term care ombudsman (LTCO) was notified of R4's facility-initiated transfers to the hospital on [DATE] and 01/12/25. On 03/04/25 at 07:58 AM, R4 sat at the dining table eating breakfast. R4 had his supplemental oxygen on. On 03/04/25 at 02:45 PM, Administrative Staff A stated the facility would send a copy of the bed-hold that was signed at admission. Administrative Staff A was not aware that a new bed-hold had to be provided and signed by the resident or representative upon a hospital stay. The facility's Bed-Holds and Returns policy revised October 2022 documented that residents and or the representatives were informed (in writing) of the facility and state (if applicable) bed-hold policies. All residents and representatives were provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospital or therapeutic leave). Residents, regardless of the payer source, were provided notice about these policies at least twice: notice 1- well in advance of any transfer (in the admission packet); notice 2- at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to the residents/representatives explain in detail: the duration of the state bed-hold policy, if any, during which the resident was permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid resident); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the stated bed-hold period (for Medicaid residents); and the facility return policy. The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave is applied to all residents regardless of payer source. Residents who sought to return to the facility within the bed-hold period defined in the state plan were allowed to return to their previous room, if available. The facility failed to provide a bed hold policy to R4 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability for R4 to return to the facility and to his previous room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents with two reviewed for accidents. Based on observation, interview, and record review the facility failed to thoroughly investigate the causative factor to prevent further falls for Resident (R)1 after she slid out of her wheelchair. This deficient practice placed R1 at risk for injuries related to falls. The facility failed to promote an environment free of hazards for Resident (R) 6 who smoked cigarettes but lacked a smoking assessment since admission to the facility. This placed the resident at risk for avoidable injuries and fire-related hazards Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of intellectual disabilities (IDD - a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), epilepsy (brain disorder characterized by repeated seizures), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and restless leg syndrome (is a condition that causes a very strong urge to move legs). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R1 required supervision for eating and extensive staff assistance for bed mobility, transfers, toileting, and dressing; R1 did not walk. The MDS documented R1 used a wheelchair and received opioid (class of drug used to reduce moderate to severe pain) medications seven days of the look-back period. The Fall Care Area Assessment (CAA), dated 02/27/25, documented R1 was at risk for falls due to diagnoses, behaviors, and weakness. The Fall Care Plan, dated 02/27/25, documented R1 had safety needs due to weakness, was at risk for falls, and stated staff would perform hourly checks in order to ensure the resident's safety. The care plan documented the resident would be laid down as soon as possible following long periods of time being up due to weakness. The care plan documented the resident had a self-care deficit, required assistance with activities of daily living, and had limited range of motion in her shoulders and knees that placed her at risk for injury. The care plan documented R1 was nonambulatory, transferred with a sling lift with two staff, and utilized a Panacea tilt chair (a mobile, pressure redistributing chair that can tilt and recline) for positioning and safety. The Fall Progress Note dated 11/14/24 at 11:11 PM, documented the resident was in a wheelchair and a Certified Nurse Aide and a Certified Medication Aide found the resident face down on the floor with the wheelchair beside her. The notes documented the resident denied hitting her head and denied pain. The facility implemented neurological checks every 15 minutes for the first hour per physician assistant order. The nurse completed a head-to-toe assessment and the resident had full range of motion to all four extremities. The Nurse's Note, dated 11/15/24 at 01:01 PM, documented R1 had an unwitnessed fall on 11/14/24 at 09:55 PM in her room. The nurse's notes documented the resident fell out of her wheelchair, with no injuries noted, vital signs were obtained, and the resident denied pain with no injuries noted. The Risk Investigation, dated 11/14/24, documented the nurse was called to R1's room after staff reported the resident was on the floor. Upon entering the resident's room, the nurse noted the resident was being assisted by staff to her bed, and a registered nurse was present with the transfer. The nurse documented the resident had been in the emergency room earlier and upon return ate a late supper staff then pushed the resident to her room in a transport manual wheelchair. The investigation report documented when staff returned to R1's room she had slid from the wheelchair to the floor. The staff documented new interventions for the staff to return the resident to her Panacea wheelchair after transport in a regular wheelchair. The investigation documented no injuries noted at the time of the accident. On 03/05/25 at 07:15 AM, R1 sat in her Panacea wheelchair in her room with a call light on the left side of the wheelchair. On 03/03/25 at 04:20 PM, Administrative Nurse E stated R1 went to the emergency room and upon return, at approximately 09:00 PM, ate a late supper. Staff then pushed R1 into her room and she was still in the manual transport wheelchair. Administrative Nurse E was unable to provide a timeline of how long the resident was in her room until staff summonsed the nurse the resident had slid out of her wheelchair. Administrative Nurse E stated the facility had done an investigation and remembers interviewing staff but was unable to provide written documentation of the witness interviews and documentation of the investigation and verify no abuse was suspected. On 03/05/25 at 09:20 AM, Administrative Staff A stated she had located a Risk Evaluation on the resident's 11/14/24 fall, but lacked a witness statement. Administrative Staff A stated she remembered interviewing staff, but failed to get written witness statements documentation and failed to view the camera footage to see if anyone walked in the room when the resident had the fall. The facility's Falls-Clinical Protocol policy, dated March 2018, documented the facility would help identify individuals with a history of falls and risk factors for falling. The staff and the practitioner would review each resident's risk factor for falling and document it in the medical record. The physician would identify medical conditions affecting fall risk and the risk for significant complications after a fall. The staff would evaluate, and document falls that occur while the individual is in the facility, for example, when and where they happen, and observations of the event. Falls should be identified as witnessed or unwitnessed events. After a resident has fallen the staff and practitioner would begin to try and identify possible causes within the first 24 hours. If the cause of the fall is unclear, or if any fall may have a significant medical cause such as a stroke or an adverse drug reaction, or if the individual continues to fall despite attempted interventions, a physician would review the situation and help further identify the cause and contributing factors. The staff and the physician would continue to collect and evaluate information until either the cause of the fall is identified, or it is determined that the cause is not found. As needed, and after an appropriate through review, the physician would document any uncorrectable risk factors and underlying causes. The facility failed to provide information and investigations that addressed the causative factor to prevent further falls for R1 after she slid out of a manual transport wheelchair. This deficient practice placed R1 at risk for injuries related to falls. - R6's Electronic Medical Record (EMR) recorded diagnoses include 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), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), nicotine dependence (a chronic characterized by a compulsive craving for nicotine), and generalized muscle weakness. R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented R6 required staff assistance with activities of daily living (ADL), lower extremities had impairment on both sides, and used a wheelchair for mobility. R6's Activities of Daily Living Care Area Assessment (CAA), dated 04/21/24, documented the resident had a stroke affecting his right side, had difficulty walking, unsteadiness on feet, and was nicotine-dependent on cigarettes. The CAA documented R6 had functional limitations to the right upper and lower extremity (right dominant side) with contracture to his right hand. The CAA documented R6 required staff assistance with dressing, hygiene, and transfers. R6's Care Plan, dated 12/31/24, documented the resident had contractures of the right hand, staff would provide skin care to keep the skin clean, and prevent skin breakdown. The care plan documented R6 was nonambulatory and utilized a wheelchair for mobility and was independent with an electric scooter. R6's Care Plan for smoking, dated 03/03/24 recorded R6 was independent with tobacco products and would sign himself out of the building, off the property through the back door, and smoke five times a day. The care plan documented the resident's cigarettes we kept at the nurse's station. R6's Smoking Safety Evaluation, dated 03/03/25, documented the resident did not have any cognitive loss, no loss or limitation with a range of motion in arms or hands. The assessment documented the resident was able to light a cigarette, hold a cigarette, extinguish a cigarette, and able to use an ashtray safely. On 03/03/25 at 12:30 PM, R6 exited the dining room dressed in street clothes, a jacket, and a ball cap on an electric scooter. At 12:45 PM staff stated R6 exited the building through the North patio doors to the driveway to go smoke. On 03/03/25 at 02:20 PM, Administrative Nurse E verified that R6 was admitted to the facility in April 2024 and the last Director of Nursing allowed the resident to go outside and smoke. Administrative Nurse E verified the facility was a smoke-free facility and the resident had to go off the premises to smoke. Administrative Nurse E stated R6 would go smoke behind the facility where a shed was located or next door at the city park. Administrative Nurse E verified the resident did not have a smoking assessment completed until the first day of the survey 03/03/25. The Employee and Tenant Smoking policy dated October 2022, documented that smoking by residents is prohibited throughout the Park Lane Nursing Home and on Park Lane Nursing Home grounds for all current and future residents. All vehicles used in connection with Park Lane Nursing Home are also smoke-free. Smoking materials, cigarettes, matches, lighters, or any other incendiary devices may not be kept in the resident's room or nursing home commons area. Employees and tenants of the facility who choose to smoke or use tobacco must smoke only in the areas outside where smoking or tobacco is permitted. The permitted area for the employees is located on the North end of the building underneath the carport. Failure to comply with the Smoking Policy will result in revocation of smoking privileges. The facility failed to assess and promote a safe environment for R6 and all the residents residing in the facility. The deficient practice placed the residents at risk for smoke or fire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 12 residents, with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility's consultant Pharmacist failed to obtain an approved indication for use for Seroquel (antipsychotic -class of medications used to treat psychosis and other mental-emotional conditions) for Residents (R) 23, R24, and Zyprexa (antipsychotic) for R15 This deficient practice placed the three residents at risk to receive unnecessary antipsychotic drugs. Findings included: - R24's Electronic Medical Record included diagnoses of insomnia (inability to sleep), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), restlessness, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, dementia (a progressive mental disorder characterized by failing memory, confusion), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), and paranoid personality disorder (a mental health condition characterized by a pervasive and unjustified pattern of distrust and suspicion of others). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS documented R24 was independent with activities of daily living, R24 received antipsychotic and antianxiety (class of medications that calm and relax people) medications. R24's Care Plan, dated 02/19/25, stated R24 had a history of mental health and mood disorders and exhibited signs of frustration, such as being short-tempered with staff and easily agitated with staff questioning which impacts the ability to ascertain accurate assessment details. R24 had a history of impulsive behavior and poor decision-making related to her health needs as she was failing to take her prescribed medications to help stabilize her moods and improve her mental health state. The care plan directed staff to distract R24 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The care plan stated R24 preferred to walk around or do word search puzzles. The care plan directed staff to cue, reorient, and supervise R24 as needed, initiated 07/03/2023. The care plan stated R24 understood consistent, simple, and directive sentences and staff were to provide her with necessary cues, stop and return if agitated, initiated 06/12/2024. The care plan directed staff to administer psychotropic medications as ordered by the physician and to monitor for side effects and effectiveness every shift, initiated 07/03/2023. The care plan stated R24 used antipsychotic medications related to depression and anxiety and directed staff to consult with the pharmacy and her physician to consider dosage reduction when clinically appropriate at least quarterly, initiated 06/12/2024. The Physician Order, dated 06/20/23, directed staff to administer Seroquel 300 milligrams (mg) at bedtime, for depression. The monthly Pharmacist Consultant reviews from 2024 and 2025 did not request an approved diagnosis or indication for the use of the antipsychotic Seroquel for R24. On 03/03/25 at 09:45 AM, R24 laid in bed, call light in reach. R24 stated she did not want to be bothered and did not want to talk later either. On 03/04/25 at 08:41 AM, Certified Medication Aide (CMA) R administered medication to R24 who was in bed. R24 took the pills whole without problems and requested an as needed Tylenol for pain rated at 7-8 in her left shoulder area. CMA R administered a Tylenol 500 mg and R24 was polite to the CMA. On 03/04/25 at 08:41 AM, CMA R stated the resident had never become upset or yelled at her. She was usually polite. On 03/05/25 at 08:50 AM, Administrative Nurse E verified depression was not an approved diagnosis for Seroquel and the consultant pharmacist had not requested an approved diagnosis for the use of Seroquel either. The facility's Pharmacy Services-Role of the Consultant Pharmacist policy, dated April 2019, stated the consultant pharmacist would provide consultation on all aspects of pharmacy services in the facility and collaborate with the facility and medical director with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. The consultant pharmacist may help to develop procedures or guidance regarding when to contact a prescriber about a medication issue. The facility's pharmacist consultant failed to obtain an approved indication or thorough rationale from the physician of why the antipsychotic Seroquel was necessary to treat R24, placing her at risk of receiving an unnecessary antipsychotic drug. - R23's Electronic Medical Record included diagnoses of viral encephalitis (inflammatory condition of the brain), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS documented R23 was independent or required supervision for all activities of daily living. The MDS documented R23 received antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) and antidepressant (a class of medications used to treat mood disorders) medication. The Behavior Care Area Assessment (CAA), dated 01/24/25, stated R23 had an episode of scratching staff and cursing them. The CAA stated R23 had ineffective coping as evidenced by verbal outbursts with anger or frustration and attention-seeking behaviors. He received Seroquel (an antipsychotic - a class of medications used to treat major mental conditions which cause a break from reality) for nicotine dependence (a compulsive need for nicotine), and the antidepressant Trazodone for restlessness and agitation. The Care Plan, dated 01/29/25, documented R23 exhibited behavioral problems secondary to a history of encephalopathy and ineffective coping as evidenced by verbal outbursts with anger or frustration and attention-seeking behaviors. R23 was known to make inappropriate comments and jokes aimed at provoking reactions from others such as staff, friends, and family. These behaviors have been observed consistently during interactions. The care plan directed staff to assist R23 to develop more appropriate methods of coping and interacting such as exercising and walking when he is frustrated. The care plan directed staff to remind R23 to talk in a normal voice range and remind him that there are others in the facility who become scared when they hear people yelling. When he became upset direct him to a private room and shut the door to converse with him about the reason he was upset, initiated 09/09/2024. The Physician Order, dated 11/07/24, directed staff to administer Seroquel, 25 milligrams (mg), twice daily, for restlessness and agitation. The Consultant Pharmacist Review on 02/05/25 (three months after the order) requested an approved diagnosis for the use of the antipsychotic Seroquel. On 03/03/25 at 11:24 AM, R23 was sitting in his recliner in his room. When the surveyor knocked on his door and spoke to him, R23 got up and walked to the doorway without his walker. R23 seemed confused and did not answer any questions. He looked out in the hall, mumbled something about staff, then got his walker and walked to the dining room. On 03/05/25 at 08:50 AM, Administrative Nurse E verified restlessness and agitation was not an approved diagnosis for the use of antipsychotic medications. She verified the consultant pharmacist had not obtained an approved diagnosis for the use of the Seroquel. The facility's Pharmacy Services-Role of the Consultant Pharmacist policy, dated April 2019, stated the consultant pharmacist would provide consultation on all aspects of pharmacy services in the facility and collaborate with the facility and medical director with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. The consultant pharmacist may help to develop procedures or guidance regarding when to contact a prescriber about a medication issue. The facility's pharmacist consultant failed to obtain an approved indication or thorough rationale from the physician of why the antipsychotic Seroquel was necessary to treat R23, placing him at risk of receiving an unnecessary antipsychotic drug. - R15's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with mood and behavioral disturbance, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and cellulitis (skin infection caused by bacteria). R15's Annual Minimum Data Set (MDS) date 07/12/24 documented she was unable to recall the current season, the location of her room, any staff names, or faces, or that she was in a nursing facility. R15 displayed physical behavioral symptoms directed toward others on one to three days during the look-back period. R15 was dependent on staff for all functional abilities and activities of daily living (ADL). R15 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an antidepressant (a class of medications used to treat mood disorders) on a regular basis. R15's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/21/24 documented she was at risk for adverse effects from Zyprexa (an antipsychotic medication) and citalopram (a medication used to treat depression). R15's Care Plan revised on 7/21/24 documented that she used the psychotic medication Zyprexa related to major depressive disorder. R15's care plan directed staff to administer medications as ordered by the physician. Staff were directed to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. R15's Order Summary Report documented a physician's order for Zyprexa 2.5 milligram (mg) tablet by mouth at bedtime for psychosis related to major depressive disorder. Review of the consultant pharmacist (CP) monthly regimen review (MRR) form Note to Attending Physician/Prescriber from January 2024 to the present for R15 lacked a recommendation to the physician for a CMS-appropriate indication for use of the antipsychotic medication Zyprexa. The 12/02/24 physician response to the Note to attending Physician/Prescriber dated 11/11/24 recommending a gradual dose reduction (GDR) of R15's Zyprexa. The physician declined the recommendation due to a good response to the medication. On 03/04/25 at 07:30 AM, R15 sat in her wheelchair in the common area of the 200 hall. R15 had a stuffed cat on her lap that she was petting. On 03/05/25 at 10:05 AM, Administrative Nurse E stated the pharmacist had not identified and recommended a CMS-appropriate diagnosis for R15's Zyprexa. Administrative Nurse E stated that the facility had done education with both the pharmacy and the physician about the use of the antipsychotic medication and the importance of an appropriate indication for use or the risk versus benefit of the medication. The Pharmacy Services - Role of the Consultant Pharmacist policy revised on April 2019, documented the CP would provide specific activities related to medication regimen review including a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. The CP would provide appropriate communication of information to prescribers and the facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. The facility failed to ensure the CP identified and reported R15's Zyprexa failed to have an adequate CMS

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R15's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with mood and behavioral disturbance, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and cellulitis (skin infection caused by bacteria). R15's Annual Minimum Data Set (MDS) date 07/12/24 documented she was unable to recall the current season, the location of her room, any staff names, or faces, or that she was in a nursing facility. R15 displayed physical behavioral symptoms directed toward others on one to three days during the look-back period. R15 was dependent on staff for all functional abilities and activities of daily living (ADL). R15 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an antidepressant (a class of medications used to treat mood disorders) on a regular basis. R15's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/21/24 documented she was at risk for adverse effects from Zyprexa (an antipsychotic medication) and citalopram (a medication used to treat depression). R15's Care Plan revised on 7/21/24 documented that she used the antipsychotic medication Zyprexa related to major depressive disorder. R15's care plan directed staff to administer medications as ordered by the physician. Staff were directed to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. R15's Order Summary Report documented a physician's order dated 08/02/23 for Zyprexa 2.5 milligram (mg) tablet by mouth at bedtime for psychosis related to major depressive disorder. This order lacked an appropriate CMS diagnosis for use. The facility had a census of 37 residents. The sample included 12 residents, with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to obtain an approved indication for use for Seroquel (antipsychotic -class of medications used to treat psychosis and other mental-emotional conditions) for Residents (R) 23, R24, and Zyprexa (antipsychotic) for R15 This deficient practice placed the three residents at risk to receive unnecessary antipsychotic drugs. Findings included: - R24's Electronic Medical Record included diagnoses of insomnia (inability to sleep), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), restlessness, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, dementia (a progressive mental disorder characterized by failing memory, confusion), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), and paranoid personality disorder (a mental health condition characterized by a pervasive and unjustified pattern of distrust and suspicion of others). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS documented R24 was independent with activities of daily living, R24 received antipsychotic, antianxiety, antidepressant, and anticoagulant medications. R24's Care Plan, dated 02/19/25, stated R24 had a history of mental health and mood disorders and exhibited signs of frustration, such as being short-tempered with staff and easily agitated with staff questioning which impacts the ability to ascertain accurate assessment details. R24 had a history of impulsive behavior and poor decision-making related to her health needs as she was failing to take her prescribed medications to help stabilize her moods and improve her mental health state. The care plan directed staff to distract R24 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book. The care plan stated R24 preferred to walk around or do word search puzzles. The care plan directed staff to cue, reorient, and supervise R24 as needed, initiated 07/03/2023. The care plan stated R24 understood consistent, simple, and directive sentences and staff were to provide her with necessary cues, stop and return if agitated, initiated 06/12/2024. The care plan directed staff to administer psychotropic medications as ordered by the physician and to monitor for side effects and effectiveness every shift, initiated 07/03/2023. The care plan stated R24 used antipsychotic medications related to depression and anxiety and directed staff to consult with the pharmacy and her physician to consider dosage reduction when clinically appropriate at least quarterly, initiated 06/12/2024. The Physician Order, dated 06/20/23, directed staff to administer Seroquel 300 milligrams (mg) at bedtime, for depression. The monthly Pharmacist Consultant reviews from 2024 and 2025 did not request an approved diagnosis or indication for the use of the antipsychotic Seroquel for R24. On 03/03/25 at 09:45 AM, R24 laid in bed, call light in reach. R24 stated she did not want to be bothered and did not want to talk later either. On 03/04/25 at 08:41 AM, Certified Medication Aide (CMA) R administered medication to R24 who was in bed. R24 took the pills whole without problems and requested an as-needed Tylenol for pain rated at 7-8 in her left shoulder area. CMA R administered a Tylenol 500 mg and R24 was polite to the CMA. On 03/04/25 at 08:41 AM, CMA R stated the resident had never become upset or yelled at her. She was usually polite. On 03/05/25 at 08:50 AM, Administrative Nurse E verified depression was not an approved diagnosis for Seroquel and the consultant pharmacist had not requested an approved diagnosis for the use of Seroquel either. The facility's Antipsychotic Medication Use policy, dated July 2022, stated residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician would identify, evaluate, and document symptoms that may warrant the use of antipsychotic medications. The policy stated diagnoses alone did not warrant the use of antipsychotic medication. In addition to an approved diagnosis, antipsychotic medication would generally only be considered if the behavioral symptoms presented a danger to the resident or others, or behavioral interventions had been attempted and included in the plan of care (except in an emergency). The policy stated antipsychotic medications would not be used if the only symptoms were one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia sadness or crying not related to depression or other psychiatric disorders, fidgeting, or uncooperativeness. The facility failed to obtain an approved indication or thorough rationale from the physician of why the antipsychotic Seroquel was necessary to treat R24, placing her at risk of receiving an unnecessary antipsychotic drug. - R23's Electronic Medical Record included diagnoses of viral encephalitis (inflammatory condition of the brain), major depressive disorder (major mood disorder which causes persistent feelings of sadness), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS documented R23 was independent or required supervision for all activities of daily living. The MDS documented R23 received antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) and antidepressant (a class of medications used to treat mood disorders) medication. The Behavior Care Area Assessment (CAA), dated 01/24/25, stated R23 had an episode of scratching staff and cursing them. The CAA stated R23 had ineffective coping as evidenced by verbal outbursts with anger or frustration and attention-seeking behaviors. He received the antipsychotic Seroquel for nicotine dependence (a compulsive need for nicotine), and the antidepressant Trazodone for restlessness and agitation. The Care Plan, dated 01/29/25, documented R23 exhibited behavioral problems secondary to a history of encephalopathy and ineffective coping as evidenced by verbal outbursts with anger or frustration and attention-seeking behaviors. R23 was known to make inappropriate comments and jokes aimed at provoking reactions from others such as staff, friends, and family. These behaviors have been observed consistently during interactions. The care plan directed staff to assist R23 to develop more appropriate methods of coping and interacting such as exercising and walking when he is frustrated. Remind R23 to talk in a normal voice range and remind him that there are others in the facility who become scared when they hear people yelling. When he became upset direct him to a private room and shut the door to converse with him about the reasons he was upset, initiated 09/09/2024. The Physician Order, dated 11/07/24, directed staff to administer Seroquel, 25 milligrams (mg), twice daily, for restlessness and agitation. The Consultant Pharmacist Review on 02/05/25 (three months after the order) requested an approved diagnosis for the use of the antipsychotic Seroquel. On 03/03/25 at 11:24 AM, R23 was sitting in his recliner in his room. When the surveyor knocked on his door and spoke to him, R23 got up and walked to the doorway without his walker. R23 seemed confused and did not answer any questions. He looked out in the hall, mumbled something about staff, then got his walker and walked to the dining room. On 03/05/25 at 08:50 AM, Administrative Nurse E verified restlessness and agitation were not an approved diagnosis for the use of antipsychotic medications. She verified the consultant pharmacist had not obtained an approved diagnosis for the use of the Seroquel. The facility's Antipsychotic Medication Use policy, dated July 2022, stated residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician would identify, evaluate, and document symptoms that may warrant the use of antipsychotic medications. The policy stated diagnosis alone does not warrant the use of antipsychotic medication. In addition to an approved diagnosis, antipsychotic medication would generally only be considered if the behavioral symptoms present a danger to the resident or others or behavioral interventions had been attempted and included in the plan of care (except in an emergency). The policy stated antipsychotic medications would not be used if the only symptoms were one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia sadness or crying not related to depression or other psychiatric disorders, fidgeting, or uncooperativeness. The facility failed to obtain an approved indication or thorough rationale from the physician of why the antipsychotic Seroquel was necessary to treat R23, placing him at risk of receiving an unnecessary antipsychotic drug.

The facility identified a census of 37 residents. The sample included 12 residents, with five residents reviewed for immunizations. Based on record review and interview the facility failed to ensure that Resident (R) 8, R5, R19, R23, and R24 were offered and educated regarding the Prevnar 20 (PCV20) pneumococcal (type of bacterial infection) vaccination (a pneumococcal conjugate vaccine that protects against 20 different strains of pneumonia) or assessed and deemed contraindicated as recommended by the Centers for Disease Control and Prevention (CDC). This deficient practice placed these residents at risk of acquiring, transmitting, or experiencing complications from pneumococcal disease. Finding included: - Review of R8's Long-Term Care Resident and Staff Annual Vaccination Acknowledgement Consent / Declination Form dated 09/19/24 was signed by R8's power of attorney (POA) declining to be vaccinated for pneumonia a (two-dose series). The form lacked distinction of all the pneumococcal vaccinations offered. Review of R15's Immunizations tab of the EMR indicated the PCV 20 had been offered to R15 but was refused. The facility was unable to provide documentation that R15 had been offered and declined specifically the PCV 20 vaccination. R15 had received the pneumococcal polysaccharide (PPSV23) on 10/11/08. Review of R19's Immunizations tab of the EMR indicated that he had received the PPSV23 vaccination on 12/06/18 and had received the Prevnar 13 (PCV13) vaccination on 09/14/17. R19's Immunizations tab or Misc. tab lacked documentation that he had been offered nor had he declined the PCV20 vaccination. Review of R23's Immunizations tab of the EMR indicated he had received the PCV 13 vaccination on 09/22/20. R23's Immunizations tab or Misc. tab lacked documentation that he had been offered nor had he declined the PCV20 vaccination. Review of R24's Immunizations tab of the EMR indicated she had received the PCV 13 on 01/31/23. R24's Immunizations tab or Misc. tab lacked documentation that he had been offered nor had declined the PCV20 vaccination. On 03/05/24 at 09:06 AM, Administrative Nurse E stated the PCV 20 she assumed was being offered to the residents. Administrative Nurse E stated the resident immunization information was sent to the pharmacy on admission and yearly and had just assumed that the PCV20 was being offered and provided per the CDC guidelines. Administrative Nurse E stated the facility would update the acceptance and declination form to include the different types of pneumococcal vaccinations. Administrative Nurse E stated the facility would talk to the pharmacy to ensure that the PCV 20 was being recommended and received by the residents as required. The Pneumococcal Vaccine policy revised on October 2023 documented all residents were offered pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections. Prior to or upon admission, the resident was assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, was offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident had completed the current recommended vaccine series. Before receiving a pneumococcal vaccine, the resident or legal representative received information and education regarding the benefits and potential side effects of the vaccine. The pneumococcal vaccines were administered to residents per the facility's physician-approved pneumococcal vaccination protocol. Administration of the pneumococcal vaccines was made in accordance with current CDC recommendations at the time of the vaccination. The facility failed to offer PCV20 vaccination as recommended by the CDC to R8, R15, R19, R23, and R24. This placed the facility residents at risk of acquiring, transmitting, or experiencing complications from pneumococcal disease.

The facility had a census of 46 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident (R) 8, placing the resident at risk for impaired wellbeing. Findings included: - On 05/09/23 at 12:20PM, dining observation revealed R8 sat in a wheelchair at an assisted dining table. Further observation revealed Nurse Aide P stood behind the resident, picked up the resident's spoon, and gave R8 a bite of food. Nurse Aide P then walked away from the table. On 05/09/23 at 12:25PM, Nurse Aide M stood beside R8, picked up R8's fork, and gave her a bite of food. Nurse Aide M then walked away from the table. On 05/09/23 at 12:35PM, Nurse Aide O sat on a chair beside R8, picked up a spoon, and gave R8 a bite of food. Nurse Aide O then stood up and walked away from the table. Further observation revealed Nurse Aide O came back to the dining table, stood by R8, picked up a spoon, and gave her a bite of food. On 05/15/23 at 09:00AM, Administrative Nurse D verified the expectation when assisting residents to eat in the dining room was the staff were to sit beside the resident when assisting with the meal. The facility's Dignity Policy, dated 2/2021, stated each resident will be cared for in a manner that enhances his or her sense of well-being and provide a dignified experience. The facility failed to promote dignity for R8, placing her at risk for an undignified experience and impaired wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 46 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide interventions for lack of bowel movements for one Resident (R) 36, who had a history of constipation (difficulty in emptying the bowels). This placed the resident at risk for impaction (the condition of being or process of becoming impacted, especially of feces in the intestine). Findings included: - The Electronic Medical Record (EMR) documented R36 had diagnoses of constipation, diabetes mellitus type 2 (the body's ability to produce or respond to the hormone insulin is impaired), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), weakness, and hemiplegia (paralysis of one side of the body)/hemiparesis (muscular weakness of one side of the body) affecting the non-dominant side. R36's Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had intact cognition and required supervision of one staff for bed mobility, transfers, ambulation, and toileting. The assessment further documented R36 was occasionally incontinent of bowel. R36's Clinical admission Evaluation, dated 11/10/22, documented R36 was alert and oriented, and was continent of bowel. The Care Plan, dated 05/05/23, documented R36 used antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) medication and directed staff to monitor, document, and report adverse reactions such as constipation, and fecal impaction. The Physician Order, dated 12/03/22, directed staff to administer Milk of Magnesia (a laxative), 30 milliliters (ml), by mouth, on the fourth day of no bowel movement, in the evening . The order further directed, if no results in the evening, continue to step three, Dulcolax (laxative) suppository, in the morning. The Physician Order, dated 03/28/23, directed Colace (stool softener), 100 milligram (mg), by mouth, daily, for constipation. The Bowel Monitoring Record, dated February 2023, revealed R36 did not have a bowel movement for the following days: 02/03/23-02/06/23 (4 consecutive days) R36's Medication Administration Record, (MAR) and clinical record for February 2023, lacked evidence the staff provided interventions or bowel assessments during the lack of bowel elimination on the above dates. The Bowel Monitoring Record, dated April 2023 and May 2023, revealed R36 did not have a bowel movement for the following days: 04/29/23 - 05/02/23 (4 consecutive days) R36's MAR and clinical record dated April 2023 through 05/02/3, lacked documentation the staff provided interventions or bowel assessments during the lack of bowel elimination on the above dates. The Nurse's Notes, dated 05/03/23 at 01:32 PM, documented R36's abdomen protruded, and was hard. R36 complained of pain of ten on a zero to 10 scale ( zero representing no pain and 10 the worst pain imaginable). The note further documented the right side of R36's abdomen bulged; he had a small loosely formed bowel movement. R36 reported his abdomen was painful upon palpation;bowel sounds were active in all four quadrants. The resident's heart rate was slightly elevated and the physician was notified and R36 went to the emergency room. The X-ray Report, dated 05/03/23, documented R36's bowel gas pattern was normal and had no evidence of a bowel obstruction (digested material is prevented from passing normally through the bowel);there was mild constipation. The Physician Order, dated 05/03/23, directed staff to start the constipation protocol. On 05/09/23 at 03:32 PM, observation revealed R36 sat in his recliner with his eyes closed. On 05/10/23 at 10:35 AM, Certified Nurse Aide (CNA) M stated, R36 had no safety awareness and often got up on his own, including toileting himself. CNA M further stated, when a resident had a bowel movement, they document in the kiosk. On 05/15/23 at 08:00 AM, Licensed Nurse (LN) H stated, there was usually a list that had resident names that had not had a bowel movement for three days and the dayshift nurse would start the bowel protocol of Milk of Magnesium. On 05/15/23 at 08:10 AM, Administrative Nurse D stated if a resident did not have a bowel movement for three days, staff were to follow the facility's bowel protocol. The facility's Bowel Regimen policy, dated May 2021, documented the policy promoted resident comfort by recognizing bowel needs through routine monitoring. A licensed nurse would assess and review bowel history and implement bowel protocols as needed. The night shift nursing staff was responsible for initiating a bowel report to identify any residents who had not had a bowel movement in the last 3 days and reporting this information on the 24-hour log, shift report sheet, and implement standing orders. The facility failed to identify periods lacking bowel movement and implement the physician ordered interventions for R36. who had a history of constipation, placing the resident at risk for impaction and decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 46 residents. The sample included 12 residents, with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to prevent the development of one facility acquired pressure ulcer for Resident (R) 38, who acquired a Stage 2 pressure ulcer (shallow with a reddish base and have a break in the top two layers of skin). The facility failed to implement interventions which included nutritional consults to promote optimal healing and prevent worsening of skin breakdown for R38. This placed the resident at risk for further breakdown. Findings included: - The Electronic Medical Record (EMR) for R38 documented diagnoses of hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), vitamin deficiency ( a condition of a long-term lack of a vitamin), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), intervertebral disc degeneration (breakdown of one or more of the discs that separate the bones of the spine causing pain in the back or neck), and weakness. R38's Significant Change Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting and extensive assistance of one staff for personal hygiene. The assessment further documented R38 was at risk for pressure ulcers, had no skin issues, no turning or repositioning program, and no pressure relieving devices for her bed or chair. The Quarterly MDS, dated 02/24/23, documented R38 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for personal hygiene. The assessment further documented R38 was at risk for pressure ulcers, had one unhealed Stage 2 pressure ulcer, had pressure relieving devices for her bed and chair, and received pressure ulcer care. The Braden Scale Assessment, dated 12/13/22, documented a score of 14, indicating a moderate risk for pressure ulcer development. The Care Plan, revised 03/02/23, originally dated 10/26/22, documented R38 had a pressure ulcer to her sacrum (large triangular bone between the two hip bones) related to limited mobility, poor nutritional intake, elimination incontinence, and directed staff to place a pressure reducing cushion in her wheelchair. An intervention, dated 06/27/22 directed staff to follow policies and protocols for the prevention of pressure ulcers, and monitor and document any changes in skin status. An intervention, dated 03/10/23, directed staff to follow Registered Dietician recommendations for wound healing. The Physician Order, dated 08/08/22, directed staff to administer a multivitamin with minerals, three tablets at bedtime, for advanced energy support. The Skin and Wound Evaluation, dated 12/15/22, documented R38 had an in house acquired Stage 2 pressure ulcer which the area measured 0.2 centimeters squared (cm) x 0.5 cm in length x 0.4 cm width. The Physician Order, dated 12/17/22, directed staff to cleanse the gluteal cleft (the groove between the buttocks that runs just below the sacrum to the perineum) region with normal saline, pat dry, and apply a foam dressing to the open area, every 72 hours, and resolve the dressing when healed. The Physician Order, dated 12/22/22, directed staff to administer Zinc (a mineral to assist with healing damaged tissues), 50 milligrams (mg), one daily for 14 days, supplement. The Skin and Wound Evaluation, dated 01/17/23, documented R38 had an in house acquired Stage 2 pressure ulcer which the area measured 0.6 cm 2 x 1.0 cm x 0.9 cm, light exudate (a mass of cells ad fluid that has seeped out of blood vessels or an organ, especially in inflammation), and had no odor. The Physician Order, dated 01/19/23, directed staff to cleanse the open area with normal saline, pat dry, apply Medihoney (medical grade honey that prevents bacteria from building in the wound), to the wound bed, cover with a foam dressing, and resume dressing changes every 72 hours and as needed, every day shift until healed. The Skin and Wound Evaluation, dated 02/19/23, documented R38's wound measured 0.5 cm 2 x 0.7 cm x 0.9 cm x 0.4 cm. The evaluation documented the wound was 50 percent (%) slough (dead tissue), 50% granulation (new tissue), light exudate, and no odor. The Physician Order, dated 02/20/23, directed staff to cleanse the open area with normal saline, pat dry, apply Cavilon barrier (helps to protect intact or damaged skin from irritation caused by urine or fecal incontinence) to periwound (the area of skin extending beyond the wound edges), let dry, and apply a small amount of hydrogel (used to increase the speed and success of wound healing) to wound bed only, cover with a dry dressing, twice a day and as needed, until healed. The Nutrition Note, dated 02/20/23 at 03:39 PM which was over two months after first identification of the Stage 2 pressure ulcer, documented R38 was assessed due to the presence of a Stage 2 pressure wound to the sacrum. R38 was on a multivitamin-mineral tablet daily, on a regular diet, received ensure supplement daily, and her daily meal intake was 51 to 75%. The note directed staff to continue with the vitamin daily, add a nutritional supplement as ordered, and documented the additional supplementation would not be helpful in the healing of the Stage 2 ulcer if nutritional intake does not decline and weight loss does not occur. The Wound and Skin Evaluation, dated 05/08/23, documented a Stage 2 pressure ulcer which measured 0.9 cm 2 x 1.6 cm x 0.8 cm x 0.1 cm, 60% slough, 40% granulation tissue, no exudate, and no odor. The Physician Order, dated 05/11/23, directed staff to cleanse the open area to sacrum with normal saline, pat dry, apply Cavilon barrier to peri- wound, let dry and apply a thin layer of hydrogel to the wound bed, and cover with a Duoderm (flexible, water proof dressing to reduce infection) dressing, change every 3 days and as needed until resolved. On 05/11/23 at 09:39 AM, Licensed Nurse (LN) I sanitized her hands, and donned gloves. R38 laid on her right side while LN I removed the old dressing, changed gloves, cleansed around the per-wound with normal saline. LN I then changed gloves, applied Cavilon barrier around the peri-wound, applied a thin layer of hydrogel to the wound, and placed a Duoderm dressing over the wound. On 05/10/23 at 10:54 AM, Certified Nurse Aide (CNA) M stated R38 had been on the other hall when she acquired the pressure area; staff encouraged her to allow them to reposition her every two hours. On 05/11/23 at 10:23 AM, LN G stated she had originally told staff not to disturb R38 at night but after R38 acquired the pressure ulcer, she told staff to encourage R38 to reposition and to change her incontinence brief. LN G further stated that there was a change in staffing, and she was now in charge of wounds and confirmed the Registered Dietician was not involved for a couple of months. LN G stated the consulting firm audited the chart and recommended the dietician be involved, and verified it was the facility policy to notify the physician and dietician when there was skin breakdown. On 05/15/23 at 08:24 AM, Administrative Nurse D stated the dietician should have been involved with the resident's care when she acquired the pressure ulcer but there had been a change in staffing at the time R38 acquired the wound. the facility's Pressure Ulcer/Skin Breakdown policy, dated April 2018, documented the nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers, and a Braden scale assessment would be completed upon admission, readmission, quarterly, and upon identification of a pressure ulcer. The policy further documented the physician would order wound treatments and although poor nutritional status was associated with increased risk for pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcers. Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status. The facility failed to implement interventions which included nutritional consults to promote optimal healing, for R38, who acquired a Stage 2 pressure ulcer. This placed the resident at risk for further breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 46 residents. The sample included 12 residents, with 10 reviewed for falls. Based on observation, record review, ad interview, the facility failed to provide a safe environment and failed to follow the care plan for two sampled residents, Resident (R) 36 and R38. This placed the resident's at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) documented R36 had diagnoses of, diabetes mellitus type 2 (the body's ability to produce or respond to the hormone insulin is impaired), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), weakness, and hemiplegia (paralysis of one side of the body)/hemiparesis (muscular weakness of one side of the body) affecting the non-dominant side. R36's Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had intact cognition and required supervision of one staff for bed mobility, transfers, ambulation, and toileting. The MDS further documented R36 had unsteady balance, no functional impairment, and had two or more non injury falls. The Morse Fall Scale, dated 04/28/23 and 05/09/23 documented the resident a high fall risk. The Fall Care Plan, dated 05/05/23, documented R36 was a high risk for falls related to gait, balance, and unaware of safety needs. The care plan directed staff to identify toileting trends for staff assistance or supervision for safety, anticipate and meet his needs, be sure his call light was within reach and respond promptly, remind resident to rise slowly, use the call light for assistance, and consult social service about replacing house shoes. The care plan directed staff R36 utilized a motion alarm in his room, and to review information on past falls and attempt to determine cause of falls. The Fall Investigation, dated 04/28/23 at 07:00 PM, documented staff responded to R36's motion alarm and found R36 on the floor by the end of the bed. The investigation further documented R36 stated he tried to go to bed, and wanted it pushed against the wall as staff had previously moved the bed away from the wall to make it and had not returned it to the proper position. The investigation documented R36 did not have any injuries and verbal education was given to staff. The Fall Investigation, dated 05/09/23 at 09:25 PM, documented staff went to R36's room to answer his call light and found him on the floor. The investigation further documented R36 stated he tried to shut his light off since staff had left on. R36 did not have any injury, staff directed R36 to call for assistance and educated staff on increasing safety checks. On 05/10/23 at 10:35 AM, observation revealed Certified Nurse Aide (CNA) M and CNA O stood on each side of R36, who had his walker in front of him. The CNAs, did not have a gait belt on the resident, per his request, and stood and pivoted R36 from his bed into his recliner. On 05/10/23 at 10:35 AM, CNA M stated R36 was impulsive and very unaware of safety concerns. CNA M further stated he would get up on his own without calling for staff assistance and would often fall. On 05/15/23 at 08:00 AM, Licensed Nurse (LN) H stated R36 was a high fall risk as he was impulsive a does not remember to call for assistance so there was a motion alarm in his room. On 05/15/23 at 08:10 AM, Administrative Nurse D stated staff were educated after both falls and should have made sure the bed was back into place as well as the light turned off for the resident. The facility Fall Prevention, Documentation, and Reporting policy, dated January 2013, documented staff identify residents at risk for falls, initiate interventions to prevent falls, reducing the risk of injury due to falls. The staff shall assess all residents for fall risk upon admission and have fall precautions implemented as appropriate, when a resident fall occurs after admission to the facility a root cause analysis shall be initiated ad an incident and accident report be completed. All trends are reported monthly to quality assurance/performance improvement committee. The facility failed to ensure a safe environment for R36. This placed the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) for R38 documented diagnoses of hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), vitamin deficiency ( a condition of a long-term lack of a vitamin), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), intervertebral disc degeneration (breakdown of one or more of the discs that separate the bones of the spine causing pain in the back or neck), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for personal hygiene. The MDS further documented R38 had unsteady balance, upper functional impairment both sides, lower functional impairment on one side, had one non injury and one injury fall since prior assessment. The Morse Fall Scale, dated 09/11/22, 09/27/22, 12/13/22, and 02/22/23, documented the resident was a high risk for falls. The Fall Care Plan, dated 03/02/23, documented R38 required two staff assistance with transfers and ambulation for short distances, be sure R38's call light was within reach, anticipate and meet her needs, and consult therapy. R38's care plan directed a chair alarm to be utilized while in wheelchair or recliner, a motion alarm to be utilized only while in bed, and to use a fall mat next to the bed when resident lying in bed; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. The Fall Investigation, dated 09/27/22 at 03:42 PM, documented R38 got up to follow staff out of her room; a different staff member intervened to provide R38 stand by assistance, and as she did this, another resident came into the hall without their walker. The investigation further documented the staff member left R38 to assist the other resident and R38 attempted to step backwards, lost her balance, and fell. The resident received a skin tear to her right elbow and a quarter size bump to the back of her head. The investigation documented R38 was taken to the emergency room and treatment was applied to the skin tear. The results of the computed tomography (CT-medical imaging used to obtain detailed internal images of the body) scans of her head were all negative. The investigation documented staff were provided education not to leave a high-risk resident unattended. The Fall Investigation, dated 02/06/23 at 08:32 PM, documented R38 was found on the floor in her room, lying on her right side with her right arm and hand underneath her face. The investigation further documented the fall alarm was on the table in her room, not turned on, and a fall matt was to be placed beside the bed. On 05/10/23 at 10:54 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N sat R38 on the said of her bed,and did not put on a gait belt, per resident request. CNA M and N stood on each side of her, stood her up and slowly transferred her into her wheelchair. On 05/10/23 at 11:00 AM, CNA M stated R38 had falls so there was a motion detector placed on the fall mat when she was in bed as well as a chair alarm. On 05/15/23 at 08:20 AM, Administrative Nurse D stated staff should follow R38's care plan and educated staff to not leave her unattended. The facility Fall Prevention, Documentation, and Reporting policy, dated January 2013, documented staff identify residents at risk for falls, initiate interventions to prevent falls, reducing the risk of injury due to falls. The staff shall assess all residents for fall risk upon admission and have fall precautions implemented as appropriate, when a resident fall occurs after admission to the facility a root cause analysis shall be initiated ad an incident and accident report be completed. All trends are reported monthly to quality assurance/performance improvement committee. The facility failed to ensure a safe environment for R38. This placed the resident at risk for further falls and injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) for R38 documented diagnoses of hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), vitamin deficiency ( a condition of a long-term lack of a vitamin), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), intervertebral disc degeneration (breakdown of one or more of the discs that separate the bones of the spine causing pain in the back or neck), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for personal hygiene. The MDS further documented R38 received an antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) medication seven days during the lookback period. R38's Black Box Warning Care Plan, dated 03/02/23, directed staff to monitor for adverse reactions, and Risperdal (an antipsychotic) medication increased mortality in elderly patients with dementia related psychosis and are at increased risk for death. R38's Abnormal Involuntary Movement Scale (AIMS) Assessment (assessment for detection of involuntary movements related to use of an antipsychotic medication), dated 03/13/23, recorded a score of 0. (a score of two or higher indicates the resident has involuntary movements). The Physician Order, dated 11/03/22, directed staff to administer Risperdal, 0.5 milligrams (mg), by mouth, twice a day, for hallucinations related to anxiety disorder. The monthly Registered Pharmacist Consultant reviews for 4/26/23, 03/22/23, 02/24/23, 01/26/23,12/26/22, 11/25/22, 10/27/22, 09/24/22, 08/24/22, and 07/20/22, lacked evidence the pharmacist identified and reported the inappropriate indication for the use of the antipsychotic medication. On 05/09/23 at 03:14 PM, observation revealed R38, in her wheelchair, by the television room. On 05/15/23 at 08:15 AM, Administrative Nurse D verified the inappropriate diagnosis for the medication and verified the pharmacist did not inform the facility. The undated Pharmacy Consultant policy stated monthly reviews of resident medications are to be done and the pharmacist is to provide recommendations for the facility and physician. The facility's failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, R38's inappropriate diagnosis for the Risperdal medication. This placed the resident at risk for adverse side effects. The facility had a census of 46 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Pharmacist Consultant identified and reported the lack of an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)39 and R38. This placed the residents at risk for unnecessary psychotropic (altering mood or thought) medication use and related consequences. Findings included: - The Electronic Medical Record (EMR) documented R39 had diagnoses of dementia, without behavioral disturbance (a disease that destroys memory and other mental functions). The Quarterly Minimum Data Set (MDS),dated 03/17/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of eight which indicated moderate impaired cognition. The MDS documented R39 received antipsychotic medication on a routine basis. The Care Area Assessment Summary (CAA) for psychotropic drug use, dated 08/10/22, documented R39 received Zyprexa (antipsychotic medication) for dementia. The Black Box Warning (strictest type of warning that the FDA (Food and Drug Administration) gives a medication, to bring major risks of taking the medication) care plan documented increased mortality for elderly patients with dementia treated with antipsychotic drugs are at an increased risk of death. The Physician's Orders, dated 10/13/22, directed the staff to administer Zyprexa 20 mg (milligrams) by mouth at bedtime for dementia without behavioral disturbance. R39's clinical record lacked evidence of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic. The monthly Registered Pharmacist Consultant reviews for 04/26/23, 03/22/23, 02/24/23, 01/26/23, 12/26/22, 11/25/22, and 10/27/22, lacked evidence the pharmacist identified and reported the inappropriate diagnoses for the use of the antipsychotic medication. On 05/09/23 at 1:00 PM, observation revealed R39 sat on a chair in her room. On 05/15/23 at 09:00AM, Administrative Nurse D verified R39 received an antipsychotic medication on a routine basis. Administrative Nurse D verified the Registered Pharmacist Consultant failed to alert the facility and physician of the inappropriate use of the antipsychotic medication. The facility's Antipsychotic Medication Use policy, dated 07/2022, stated antipsychotic medications are used for a specific condition and will only be used based on the comprehensive assessment. The undated Pharmacy Consultant policy stated monthly reviews of resident medications are to be done and the pharmacist is to provide recommendations for the facility and physician. The facility failed to ensure the Registered Pharmacist Consultant failed identified and reported the lack of an appropriate indication for the use of an antipsychotic medication for R39 placing the resident at risk for adverse medication reactions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) for R38 documented diagnoses of hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), vitamin deficiency ( a condition of a long-term lack of a vitamin), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), intervertebral disc degeneration (breakdown of one or more of the discs that separate the bones of the spine causing pain in the back or neck), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for personal hygiene. The MDS further documented R38 received an antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) medication seven days during the lookback period. R38's Black Box Warning Care Plan, dated 03/02/23, directed staff to monitor for adverse reactions, and Risperdal (an antipsychotic) medication increased mortality in elderly patients with dementia related psychosis and are at increased risk for death. R38's Abnormal Involuntary Movement Scale (AIMS) Assessment (assessment for detection of involuntary movements related to use of an antipsychotic medication), dated 03/13/23, recorded a score of 0. (a score of two or higher indicates the resident has involuntary movements). The Physician Order, dated 11/03/22, directed staff to administer Risperdal, 0.5 milligrams (mg), by mouth, twice a day, for hallucinations related to anxiety disorder. The Pharmacy Regimen Review, dated 04/26/23, recommended a risk versus benefit for the Risperdal medication but did not documented the inappropriate diagnosis. R38's clinical record lacked evidence of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management for the continued use of an antipsychotic. On 05/09/23 at 03:14 PM, observation revealed R38, in her wheelchair, by the television room. On 05/15/23 at 08:15 AM, Administrative Nurse D verified the inappropriate diagnosis for the medication and verified the pharmacist did not inform the facility. The facility's Antipsychotic Medication Use policy, dated 07/2022, stated antipsychotic medications are used or a specific condition and will only be used based on the comprehensive assessment. The facility failed to have an appropriate indication for the use of an antipsychotic medication for R38, placing the resident at risk for adverse medication reaction. The facility had a census of 46 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to provide an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for resident (R)39 and R38. This placed the residents at risk for unnecessary psychotropic ( altering mood or thought) medication use and related consequences. Findings included: - The Electronic Medical Record (EMR) documented R39 had diagnoses of dementia, without behavioral disturbance (a disease that destroys memory and other mental functions). The Quarterly Minimum Data Set (MDS),dated 03/17/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of eight which indicated moderate impaired cognition. The MDS documented R39 received antipsychotic medication on a routine basis. The Care Area Assessment Summary (CAA) for psychotropic drug use, dated 08/10/22, documented R39 received Zyprexa (antipsychotic medication) for dementia. The Black Box Warning (strictest type of warning that the FDA (Food and Drug Administration) gives a medication, to bring major risks of taking the medication) care plan documented increased mortality for elderly patients with dementia treated with antipsychotic drugs are at an increased risk of death. The Physician's Orders, dated 10/13/22, directed the staff to administer Zyprexa 20 mg (milligrams) by mouth at bedtime for dementia without behavioral disturbance. R39's clinical record lacked evidence of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic. On 05/09/23 at 1:00 PM, observation revealed R39 seated on a chair in her room. On 05/15/23 at 09:00AM, Administrative Nurse D verified R39 received an antipsychotic medication on a routine basis. Administrative Nurse D verified dementia was an inappropriate diagnosis for the use of the antipsychotic medication. The facility's Antipsychotic Medication Use policy, dated 07/2022, stated antipsychotic medications are used for a specific condition and will only be used based on the comprehensive assessment. The facility failed to have an appropriate indication for the use of an antipsychotic medication for R39 placing the resident at risk for adverse medication reactions.

The facility identified a census of 41 residents with three residents reviewed for abuse and neglect. Based on record review and interview, the facility failed to protect Resident (R) 1 from abuse of physical restraint when Certified Nurse's Aide (CNA) M restrained R1 by placing her forearm across R1's upper thighs to keep R1 from moving which caused bruises to R1's upper right thigh measuring 13 centimeters (cm) by 6.5 cm that were blue/green to purple in color and in an oblong shape and bruises to her upper left thigh measuring 6.5 cm by 4.5 cm blue/green to purple in color and oval in shape. This deficient practice of manually restraining R1 to keep her from moving placed R1 at risk for injury and impaired psychosocial well-being. Findings included: - R1's Electronic Medical Record documented diagnoses of vascular dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated 10/21/22, documented R1 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. The MDS further documented R1 was totally dependent on two staff for transfers, required extensive assistance of two staff for bed mobility, dressing, and toilet use, and required extensive assistance of one staff for locomotion, personal hygiene, and eating. The Activity of Daily Living (ADL) Care Plan, dated 10/21/22, documented R1 required assistance with ADLs. The care plan instructed staff R1 required assistance of one staff for bed mobility, incontinence care, eating, personal hygiene, and bathing. The care plan instructed staff R1 required two staff assistance using a total lift for transfers. The Dementia/Anxiety Care Plan, dated 10/21/22, documented R1 often exhibited repetitive movements and restlessness. The care plan instructed staff to give R1 clear explanations of any care given, provide R1 opportunities for choice during cares, and to provide R1 consistency with cares to promote comfort with ADL's. The Facility Incident Report, dated 12/13/22, documented on the night shift of 12/08/22 to 12/09/22 on the 10:00 PM to 06:00 AM shift, R1 was restless in bed. CNA M entered R1's room at 11:10 PM with R1's wheelchair and remained in R1's room until 11:13 PM. During CNA M's time in R1's room, CNA M claimed R1 had thrown her pillow onto the floor, so CNA M picked the pillow up and returned it to R1 and CNA M resumed stocking R1's room. R1 continued to be restless and threw her pillow again. CNA M stated she tried to reposition R1 and the bed was unlocked and made a banging noise against the wall and R1 had hit the wall with her hand a couple of times. Licensed Nurse (LN) G, LN H, and CNA N were at the nurse's station and heard the banging coming from R1's room. LN G hollered out, What's going on in there? CNA M reported to the other staff the bed was not locked and R1 had hit her hand against the wall a couple of times. LN G, LN H, and CNA N did not go into R1's room at this time as they were in close enough proximity at the nurse's station to hear CNA M's answer. CNA M went into R1's room again on 12/09/22 at 12:03 to 12:05 AM and reported R1 was continuing to be restless and was repeatedly kicking her blankets off and was causing her motion sensor to alarm. CNA M went back into R1's room at 12:12 AM to 12:17 AM and then again at 02:03 to 02:08 AM. At 02:34 AM, CNA M and CNA N went into R1's room to provide R1 with cares and get her up to her chair due to R1 continuing to be restless. At this time, CNA N noticed the bruises to the top of R1's thighs. CNA N reported she heard CNA M say watch they will try to pin that on me. CNA N reported the bruises to LN G and she assessed R1's bruises and then asked LN H to come to the unit to assist her. LN G and LN H sent CNA M on break outside of the facility and called Administrative Nurse D regarding possible abuse at 03:04 AM. Administrative Nurse D arrived to the facility at 03:15 AM. CNA M returned to the facility and the Administrative Nurse D instructed CNA M to leave and discontinue her duties as an aide. R1 was assesed to have a blue-green to purple colored bruise to her right upper thigh consistent with a ecchymosis (bruising) that measured 13 cm by 6.5 cm, was oblong in shape, and had varying degrees of firmness with palpation consistent with a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). R1's left upper thigh had sustained a bruise that was blue-green to purple in color, was oval in shape, and had the same varying degrees of firmness with palpation that measured 6.5 cm by 4.5 cm. Administrative Nurse D asked R1 if someone had placed their hands on her and R1 said yes and pointed to her legs. Law enforcement was called, and the law enforcement officer asked CNA M to come to the police station to make a statement. The Witness Statement, dated 12/09/22, documented CNA N stated R1was setting off her floor alarm by moving her feet. CNA N went into R1's room to ask R1 why she was trying to get out of bed. R1 stated she wanted to get up. CNA N asked R1 if she wanted to get up to her chair and eat a snack and R1 replied, Yes. CNA N raised the bed up and pulled back R1's covers and saw the bruises on R1's legs. CNA N stepped out of the room and asked LN G if any bruising had been reported to her. LN G checked her paperwork and then went into R1's room to assess the bruises. LN G left R1's room to go and get LN H. CNA N brought R1 out to the sitting room and put on a movie for her to watch and fed her a pudding and gave her something to drink. R1 was content. The Witness Statement, dated 12/09/22, documented LN G stated on 12/08/22 at 11:30 PM she and CNA N had been sitting in the nurse's station when she heard banging on the wall coming from R1's room. LN G stated there was two to three banging noises with one of the banging noises being R1's bed hitting the wall and the other two banging noises were unfamiliar to LN G. LN G stated she yelled, What is going on in there? LN G stated CNA M replied, She [R1] keeps getting out of bed. LN G stated R1 had been restless. Later in the night at approximately 02:30 AM, CNA M and CNA N went to get R1 up to her chair per R1's request as R1 was restless again. CNA N yelled for LN G to come see R1's legs. LN G stated when she arrived at R1's room she saw bruising to R1's legs. The right leg bruise measured 6 cm by 10 cm and the left leg bruise measured 4 cm by 3 cm and 3 cm by 1 cm. LN G stated all three bruises were fresh with dark blue centers fading to light blue around the edges and were slightly raised. R1 stated the areas hurt after LN G assessed them. LN G asked CNA M and CNA N where the bruises came from. CNA M stated, Those are old. LN G then went and got LN H to assist. R1 was up in her chair and was content. LN G stated she and LN H called the Administrative Nurse D to come to the facility. The Witness Statement, dated 12/09/22, documented LN H stated LN G had come to her regarding R1's bruising to her legs. LN H went to assess R1 and noted blue bruising to the top of R1's bilateral legs with lumps under the bruising. LN H stated she and LN G tried to piece together plausible scenarios of how the bruises had been sustained without any luck. LN H took CNA M into the break room to talk to her about the bruises to R1. CNA M stated, She [R1] was restless and I was trying to put a pillow in place. When I rolled her, she was banging on the walls. I noticed the bruises earlier and meant to tell LN G but I forgot. The Skin/Wound Note, dated 12/10/22, documented bruises noted to R1's upper thighs bilaterally. The bruises are dark blue in the center fading to light blue around the edges. The Skin/Wound Note, dated 12/11/22, documented bruising continues to R1's bilateral upper thighs. The left thigh has two bruises both are had and dark blue in the middle fading to light blue around the edges. The right thigh bruise has increased in size and the dark blue area continues to be hard to the touch. R1 reports the areas hurt. The Skin/Wound Note, dated 12/12/22, documented R1 continued to have bruising to her bilateral upper thighs. The area on the right thigh continued to be hard. The area has yellow around the edges and the middle continues to be a dark blue. The bruises to the left thigh continued to be dark blue in the center and fade to light blue around the edges. R1 complained of pain to all areas. The Skin/Wound Note, dated 12/13/22, documented R1 continued to have bruising to her bilateral upper thighs. The left thigh bruises both had dark blue centers with light blue around the edges. The right thigh bruise had a dark blue center with yellow around the edges and continues to be hard to the touch. R1 complained of pain to all affected areas. The Skin/Wound Note, dated 12/20/22, documented R1 continue to have bruising to her bilateral thighs. The left thigh bruise had green/yellow discoloration and the right thigh is purple to yellow in discoloration with a large knot. The Skin/Wound Note, dated 12/26/22, documented R1 continued to have bruising to her bilateral upper thighs. Bruising to the left thigh was lightening up in comparison to the right thigh which was still pink/red in color. A lump was still noted to the right thigh. R1 denied pain to the areas. The Skin/Wound Note, dated 12/30/22, documented the bruising to R1's right thigh continued to fade. There continue to be a large, firm, raised hematoma like area remained to the site since the first notation on 12/09/22. No redness or warmth were noted. R1 denied pain to the area. The Skin/Wound Note, dated 01/02/23, documented the bruising to R1's bilateral thighs had faded. The areas continue to be hard to touch and slightly raised. R1 denied pain. On 01/09/23 at 01:30 PM, the law enforcement officer stated that CNA M had admitted that she had placed her forearm across R1's upper thighs to keep her from moving so she cover her up with a blanket and quickly exit the room. On 01/09/23 at 01:45 PM, R1's representative stated that R1 was dependent on the facility for all of the care that she needed. R1's representative stated R1 still had bruises to the tops of her thighs and it had been a month since it had happened. On 01/09/23 at 02:00 PM, Administrative Nurse D stated that CNA M told her that R1 kept kicking off her blankets and that her arms may have come into contact with R1's legs when she was replacing the blanket. Administrative Nurse D stated that routine care does not typically result in injury to a resident. Administrative Nurse D stated under no circumstances were residents to be held down against their will. The facility's Abuse, Neglect, and Exploitation, policy, dated February 2017, documented abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. All elders of the facility will be free of physical, emotional, and sexual abuse, neglectful treatment, and misappropriation of funds and resources. The facility failed to protect R1 from abuse when CNA M restrained R1 with her forearm placed across R1's upper thighs to keep R1 from moving which caused bruises to R1's upper bilateral thighs. This deficient practice of restraining R1 to keep her from moving placed R1 at risk for injury and impaired psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R) 10's Physician Order Sheet (POS), dated 09/08/21, documented diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) with psychotic features, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disorder (mental disorder characterized by a gross impairment in reality testing) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had moderately impaired cognition, physical behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others which occurred one to three days of the look back period. The MDS further documented R10 received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), and hypnotic (a sleep inducing drug) seven days during the look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/29/21, had not been completed. The Care Plan dated 08/10/21, recorded the resident chose to isolate herself in her room, had diagnoses of anxiety, depression with psychosis, periods of paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), and fabricate situations or ideas when anxious. The care plan further recorded the resident received Xanax (medication to treat anxiety) as needed for anxiety which is a Black Box Warning (BBW - these warnings communicate potential rare but dangerous side effects) medication, which directed to limit dosages and durations to the minimum required, and follow patients for signs and symptoms of respiratory depression and sedation. The Physician Order Sheet (POS), dated 09/08/21, directed staff to administer Xanax 0.25 milligrams (mg) by mouth every eight hours PRN for anxiety. The start date for the order was 02/01/21 and did not include a required stop date. The Pharmacist Record Review, dated 04/21/21, documented a request for a risk versus benefit statement for the use of Xanax from the physician. The request lacked guidance for 14-day discontinuation. The Pharmacy Record Reviews, dated 05/24/21, 06/21/21, 07/14/21, and 08/11/21, did not address the use of the PRN Xanax without a stop date. The Pharmacist Record Review, dated 09/08/21, documented a request to the physician for a gradual dose reduction of Xanax 0.25 mg every eight hours PRN. The pharmacist's note lacked guidance for a 14 day discontinuation for PRN antianxiety medication. The physician responded, do not attempt to taper the dose of the medication due to chronic anxiety. The Progress Note dated 09/08/21 at 08:01 PM, documented the physician saw the resident earlier in the day, and the resident had no complaints or concerns. The note further documented vital signs and medication reviewed and no changes were ordered. On 10/04/21 at 09:07 AM, observation revealed the resident was anxious to lie in bed and staff transferred the resident to her bed. On 10/04/21 at 02:50 PM, Administrative Nurse D stated as needed psychotropic medications should have a stop date of 14 days. She had expected the pharmacy consultant to have recognized the orders did not have a stop date and the pharmacist had not notified the physician, the medical director, or her of the lack of stop date for the use of the PRN Xanax. On 10/06/21 at 10:25 AM, Pharmacy Consultant (PC) GG stated the prn psychotropic medication should have a stop date. She stated a stop date of 14 days should be in place, and then a review/evaluate the need for continued use of the medication by the ordering practitioner. The facility's Monthly Medication Review policy, dated October 2021, documented the consultant pharmacist provides a review and analysis of prescribed medication therapy and medication use review, including nursing documentation of medication ordering and administration. Findings and recommendations are reported to the administrator, Director of Nursing, the responsible physician, and the Medical Director. The facility's consultant pharmacist failed to notify the Director of Nursing, the medical director, or the physician of the lack of required stop date for R10's PRN Xanax, placing the resident at risk for receiving unnecessary psychotropic medication. -R33's Quarterly Minimum Data Set, (MDS) dated [DATE], documented R33 with intact cognition, had inattention and disorganized thinking which fluctuated. The MDS further documented the resident received antianxiety and antidepressant medication seven days of the look back period. The Psychotropic Drug Use Care Area Assessment, (CAA) dated 04/02/21, documented the resident took Ativan (medication for the treatment of anxiety) 0.5 milligrams (mg) four times a day for anxiety. The Medication Care Plan, dated 09/14/21, documented the resident may feel down and depressed, took Ativan which had a Black Box Warning (BBW- these warnings communicate potential rare but dangerous side effects) PRN for anxiety. The Physician Order Sheet, dated 08/11/21, directed staff to administer Ativan 0.5 milligrams (mg) four times a day for anxiety disorder. The order further directed staff to administer Ativan 1 mg PRN four times for anxiety. The PRN Ativan start date for the order was 05/07/21 and did not include a required stop date. The Pharmacist Record Review, dated 05/31/21, 07/29/21, 08/28/21, and 09/23/21, lacked documentation regarding a stop date for the use of PRN Ativan. The Pharmacist Record Review, dated 06/24/21, documented a request for a risk versus benefit statement for the use of Ativan. On 10/04/21 at 01:29 PM, observation revealed R33 at her doorway with her walker inquiring about the afternoon activities and was eager to attend. On 10/04/21 at 04:28 PM, Administrative Nurse D verified the resident's Ativan order lacked a stop date and the pharmacist had not notified the physician, the medical director, or her of the lack of stop date for the use of the PRN Ativan. On 10/06/21 at 10:25 AM, Pharmacy Consultant (PC) GG stated the prn psychotropic medication should have a stop date. She stated a stop date of 14 days should be in place, and then a review/evaluate the need for continued use of the medication by the ordering practitioner. The facility's Monthly Medication Review policy, dated October 2021, documented the consultant pharmacist provides a review and analysis of prescribed medication therapy and medication use review, including nursing documentation of medication ordering and administration. Findings and recommendations are reported to the administrator, Director of Nursing, the responsible physician, and the Medical Director. The facility's consultant pharmacist failed to notify the Director of Nursing, the medical director, or the physician of the lack of required stop date for R33's PRN Ativan, placing the resident at risk for receiving unnecessary psychotropic medication. The facility had a census of 43 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review the facility's consultant pharmacist failed to notify the Director of Nursing, medical director, or the residents' physicians regarding six of six sampled residents' PRN (as needed) psychotropic medications (chemical substance that changes nervous system function and results in alterations in perception, mood, consciousness, cognition, or behavior) lacked a required stop date, Resident (R) 26, R32, R10, and R33. Findings included: - R26's Significant Change Minimum Data Set (MDS), dated [DATE], documented severely impaired decision making, and received antipsychotic (used to treat psychotic disorders), and antidepressive (used to alleviate depression) medications 7 days of the lookback period. The Care Area Assessment (CAA), dated 08/11/21, documented R26 received Ativan (antianxiety medication) as needed for severe anxiety. These medications are associated with Black Box Warnings (BBW) (these warnings communicate potential rare but dangerous side effects). The Medication Care Plan, dated 08/25/21, directed staff to provide medications to alleviate agitation as physician ordered, monitor and document side effects and effectiveness. R26 used to respond well to familiar staff; however, she doesn't seem to recognize people anymore. This often leads to an increase in frustration and anxiety, ask yes or no questions in order to determine the resident's needs. The care plan included the BBW for Ativan, may result in sedation, respiratory depression, or death. The Physician Order, dated 02/02/21, directed staff to administer to R26 Ativan, 0.5 milligrams (mg), three times daily as needed for severe anxiety. The order did not include a required stop date. The Consultant Pharmacist Reviews dated 02/24/21, 03/27/21, 04/21/21, 05/24/21, 06/21/21, 07/29/21, 08/28/21, and 09/23/21 did not address the use of the PRN Ativan without a stop date. On 02/24/21 and 06/24/21 the consultant pharmacist requested a risk versus benefit statement for the continued use of Ativan but did not request a stop date. On 09/29/21 at 04:51 PM, observation revealed R26 seated in a recliner in her room. R26 appeared calm and more alert than earlier in the day. On 10/04/21 at 07:50 AM, Certified Medication Aide (CMA) S stated the resident showed anxiety or agitation when staff rolled her over during cares. CMA S stated PRN Ativan was rarely used. On 10/04/21 at 04:28 PM, Administrative Nurse D verified the resident's Ativan order lacked a stop date and the facility's consultant pharmacist had not notified the physician, the medical director, or her of the lack of stop date for the use of the PRN Ativan. On 10/06/21 at 10:20 AM, Consultant Pharmacist (CP) GG verified the PRN antianxiety medications required an initial stop date of 14 days, and then could be ordered for longer if needed. The facility's Monthly Medication Review policy, dated October 2021, documented the consultant pharmacist provides a review and analysis of prescribed medication therapy and medication use review, including nursing documentation of medication ordering and administration. Findings and recommendations are reported to the administrator, Director of Nursing, the responsible physician, and the Medical Director. The facility's consultant pharmacist failed to notify the Director of Nursing, the medical director, or the physician of the lack of required stop date for R26's PRN Ativan. - R32's Significant Change Minimum Data Set (MDS), dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R32 received antianxiety medication (drug used to relieve anxiety) four days of the lookback period. R32's Care Plan, dated 07/22/21, documented the resident received Black Box Warning (BBW- these warnings communicate potential rare but dangerous side effects) medications. The Physician Order, dated 09/09/21, directed staff to administer PRN Ativan, 0.5 milligrams (mg) every four hours, as needed. The order lacked a stop date. The Pharmacist Review, dated 09/23/21 lacked recommendation to include a stop date for the PRN Ativan. On 09/30/21 at 09:53 AM, observation revealed R32 seated in bed when Certified Medication Aide (CMA) S administered medications to him without problems. On 10/04/21 at 04:28 PM, Administrative Nurse D verified the resident's Ativan order lacked a stop date and the pharmacist had not notified the physician, the medical director, or her of the lack of stop date for the use of the PRN Ativan. On 10/06/21 at 10:20 AM, Consultant Pharmacist (CP) GG verified the PRN antianxiety medications required an initial stop date of 14 days, and then could be ordered for longer if needed. The facility's Monthly Medication Review policy, dated October 2021, documented the consultant pharmacist provides a review and analysis of prescribed medication therapy and medication use review, including nursing documentation of medication ordering and administration. Findings and recommendations are reported to the administrator, Director of Nursing, the responsible physician, and the Medical Director. The facility's consultant pharmacist failed to notify the Director of Nursing, the medical director, or the physician of the lack of required stop date for R32's PRN Ativan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R) 10's Physician Order Sheet (POS), dated 09/08/21, documented diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) with psychotic features, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disorder (mental disorder characterized by a gross impairment in reality testing) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had moderately impaired cognition, physical behavioral symptoms directed toward others and other behavioral symptoms not directed toward others which occurred one to three days of the look back period. R10 required extensive assistance of two staff with activities of daily living. The MDS further documented R10 received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), and hypnotic (a sleep inducing drug) seven days during the look back period. The antipsychotic had been received on a routine basis. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/29/21, had not been completed. The Care Plan dated 08/10/21, recorded the resident chose to isolate herself in her room, had diagnoses of anxiety, depression with psychosis, periods of paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), and fabricate situations or ideas when anxious. The care plan further recorded the resident received Xanax (medication to treat anxiety) as needed for anxiety which is a Black Box Warning (BBW - these warnings communicate potential rare but dangerous side effects) medication, which directed to limit dosages and durations to the minimum required, and follow patients for signs and symptoms of respiratory depression and sedation. The Physician Order Sheet (POS), dated 09/08/21, directed staff to administer Xanax 0.25 milligrams (mg) by mouth every eight hours PRN for anxiety. The start date for the order was 02/01/21 and did not include a required stop date. The Pharmacist Record Reviews, dated 03/07/21, 05/24/21, 06/21/21, 07/14/21, and 08/11/21, lacked documentation regarding the use of PRN Xanax. The Pharmacist Record Review, dated 04/21/21, documented a physician request for a risk versus benefit statement for the use of Xanax. The request lacked guidance for a 14- day discontinuation. The Pharmacist Record Review, dated 09/08/21, documented a request to the physician for a gradual dose reduction of Xanax 0.25 mg every eight hours prn. The pharmacist's note lacked guidance for a 14-day discontinuation for as needed antianxiety medication. The physician responded, do not attempt to taper the dose of the medication due to chronic anxiety. The Progress Note, dated 09/08/21 at 08:01 PM, documented the physician saw the resident earlier in the day, and the resident had no complaints or concerns. The note further documented vital signs and medication reviewed and no changes were ordered. On 10/04/21 at 02:50 PM, Administrative Nurse D stated as needed psychotropic medications should have a stop date of 14 days. She had expected the pharmacy consultant to have recognized the orders did not have a stop date. The facility's Medication Administration policy, dated August 2021, documented a healthcare provider's order that includes dosage, route, frequency, duration when necessary, and other required considerations is required for administration of medication. The facility failed to obtain a required stop date for the use of the PRN Xanax for R10, placing the resident at risk for receiving unnecessary psychotropic medication. - R33's Physician Order Sheet, (POS), dated 08/11/21, documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), insomnia (inability to sleep), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), vascular dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The Quarterly Minimum Data Set, (MDS) dated [DATE], documented R33 had intact cognition, had inattention and disorganized thinking which fluctuated, required extensive assistance of one staff for activities of daily living. The MDS further documented the resident received antianxiety and antidepressant seven days of the look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 04/02/21, documented the resident took Ativan (medication for the treatment of anxiety) 0.5 milligrams (mg) four times a day for anxiety. The Medication Care Plan, dated 09/14/21, documented the resident may feel down and depressed. She takes Ativan which is a Black Box Warning (BBW - these warnings communicate potential rare but dangerous side effects) medication as needed for anxiety. The Physician Order Sheet (POS), dated 08/11/21, directed staff to administer Ativan 0.5 mg four times a day for anxiety disorder. The order further directed staff to administer Ativan 1 mg PRN four times for anxiety. The start date for the order was 05/07/21 and did not include a required stop date. The Pharmacist Record Reviews, dated 05/31/21, 07/29/21, 08/28/21 and 09/23/21, lacked documentation regarding the use of PRN Ativan. The Pharmacist Record Review, dated 06/24/21, documented a request for a risk versus benefit statement for the use of Ativan. On 10/04/21 at 02:50 PM, Administrative Nurse D stated as needed psychotropic medications should have a stop date of 14 days. She had expected the pharmacy consultant to have recognized the orders did not have a stop date. The facility's Medication Administration policy, dated August 2021, documented a healthcare provider's order that includes dosage, route, frequency, duration when necessary, and other required considerations is required for administration of medication. The facility failed to obtain a required stop date for the use of the PRN Ativan for R33 placing the resident at risk for receiving unnecessary psychotropic medication. - Resident (R) 18's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition, and disorganized thinking which fluctuated. The MDS further documented R18 received an antianxiety and antidepressant seven days of the look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 08/12/21, documented R18 was treated daily with an antidepressant and an antianxiety daily with PRN Ativan 0.25 milligram (mg) every 12 hours for the treatment of anxiety. R18's Care Plan, dated 08/19/21, lacked documentation regarding the use of PRN Ativan. The Physician Order, dated 09/07/21, directed staff to administer PRN Ativan 0.5 mg, give half a tablet for a 0.25 mg dose, every 12 hours. The start date for the PRN Ativan was 02/01/21 and did not include a required stop date. The Progress Note, dated 05/07/21 at 03:33 PM documented the physician had seen the resident for a routine visit. The physician was notified of gradual dose reduction recommendation for Ativan and no changes ordered. On 09/30/21 at 07:51 AM, observation revealed the resident wheeled herself out of her room and requested help for her knee and shoulder pain. On 10/04/21 at 04:28 PM, Administrative Nurse D verified the resident's Ativan order lacked a stop date. The facility's Medication Administration policy, dated August 2021, documented a healthcare provider's order that includes dosage, route, frequency, duration when necessary, and other required considerations is required for administration of medication. The facility failed to obtain a required stop date for the use of the PRN Ativan for R18 placing the resident at risk for receiving unnecessary psychotropic medication. - R29's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive impairment, inattention, disorganized thinking, and other behavioral symptoms not directed toward others which occurred one to three days of the look back period. The MDS further documented the resident received antianxiety, antidepressant, anticoagulant, and diuretic seven days of the look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 05/26/21, documented R29 had vascular dementia and had daily antidepressant medication for the treatment of depression. The Medication Care Plan dated 09/07/21, lacked documentation addressing the use of Xanax. The Physician Order Sheet, dated 09/07/21, directed staff to administer Xanax (a drug used to relieve anxiety) 0.25 milligrams (mg) every eight hours PRN for anxiety. The start date for the order was 06/17/21 and did not include a required stop date. On 10/04/21 at 09:39 AM, observation revealed R29 taking her medication from the Certified Medication Aid without difficulty. On 10/04/21 at 04:28 PM, Administrative Nurse D verified the resident's Xanax order lacked a stop date . The facility's Medication Administration policy, dated August 2021, documented a healthcare provider's order that includes dosage, route, frequency, duration when necessary, and other required considerations is required for administration of medication. The facility failed to obtain a required stop date for the use of the PRN Xanax for R29 placing the resident at risk for receiving unnecessary psychotropic medication. The facility had a census of 43 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure six of six sampled residents' PRN (as needed) psychotropic medications (chemical substance that changes nervous system function and results in alterations in perception, mood, consciousness, cognition, or behavior) had a required stop date, Resident (R) 26, R32, R10, R33, R18, and R29. Findings included: - R26's Significant Change Minimum Data Set (MDS), dated [DATE], documented severely impaired decision making, and received antipsychotic (used to treat psychotic disorders), and antidepressive (used to alleviate depression) medications seven days of the lookback period. The Care Area Assessment (CAA), dated 08/11/21, documented R26 received Ativan (antianxiety medication) as needed for severe anxiety. These medications are associated with Black Box Warnings (BBW - these warnings communicate potential rare but dangerous side effects). The Medication Care Plan, dated 08/25/21, directed staff to provide medications to alleviate agitation as physician ordered, monitor and document side effects and effectiveness. R26 used to respond well to familiar staff; however, she doesn't seem to recognize people anymore. This often leads to an increase in frustration and anxiety, ask yes or no questions in order to determine the resident's needs. The care plan included the BBW for Ativan, may result in sedation, respiratory depression, or death. The Physician Order, dated 02/02/21, directed staff to administer to R26 Ativan, 0.5 milligrams (mg), three times daily as needed for severe anxiety. The order did not include a required stop date. The Consultant Pharmacist Reviews dated 02/24/21, 03/27/21, 04/21/21, 05/24/21, 06/21/21, 07/29/21, 08/28/21, and 09/23/21 did not address the use of the PRN Ativan without a stop date. On 02/24/21 and 06/24/21 the consultant pharmacist requested a risk versus benefit statement for the continued use of Ativan but did not request a stop date. On 09/29/21 at 04:51 PM, observation revealed R26 seated in a recliner in her room. R26 appeared calm and more alert than earlier in the day. On 10/04/21 at 07:50 AM, Certified Medication Aide (CMA) S stated the resident showed anxiety or agitation when staff rolled her over during cares. CMA S stated PRN Ativan was rarely used. On 10/04/21 at 04:28 PM, Administrative Nurse D verified the PRN Ativan should have a stop date. The facility's Medication Administration policy, dated August 2021, documented a healthcare provider's order includes dosage, route, frequency, duration when necessary, and other required considerations. The facility failed to obtain a required stop date for the use of the PRN Ativan for R26, placing the resident at risk for receiving unnecessary psychotropic medications. - R32's Significant Change Minimum Data Set (MDS), dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R32 received antianxiety medication (drug used to relieve anxiety) four days of the lookback period. R32's Care Plan, dated 07/22/21, documented the resident received Black Box Warning (BBW- these warnings communicate potential rare but dangerous side effects) medications. The Physician Order, dated 09/09/21, directed staff to administer PRN Ativan, 0.5 milligrams (mg) every four hours, as needed. The order lacked a stop date. The Pharmacist Review, dated 09/23/21 lacked recommendation to include a stop date for the PRN Ativan. On 09/30/21 at 09:53 AM, observation revealed R32 seated in bed when Certified Medication Aide (CMA) S administered medications to him without problems. On 10/04/21 at 04:28 PM, Administrative Nurse D verified the resident's Ativan order lacked a stop date. The facility's Medication Administration policy, dated August 2021, documented a healthcare provider's order includes dosage, route, frequency, duration when necessary, and other required considerations. The facility failed to obtain a required stop date for the use of the PRN Ativan for R32, placing the resident at risk for receiving unnecessary psychotropic medications.

The facility had a census of 43 residents. The sample included 13 residents. Based on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan (a written plan containing the process that would guide the nursing homes efforts in assuring care and services were maintained at acceptable levels of performance and continually improved). Findings included: - Review of the QAPI plan as provided by Administrative Nurse E revealed a blank plan. On 10/05/21 at 04:02 PM, Administrative Nurse E reported she had begun a Performance Improvement Plan (PIP) when the facility switched their electronic record program to another source in February 2021. She reported this is ongoing as the facility's staff learn to utilize the current system to capture the full advantage of this form of record utilization. Administrative Nurse E reported she was not aware of the structured PIP from the other departments of the facility. She lacked documentation of departments structured areas of issues and plan to monitor and evaluate the plan for improvement. She did state the Quality Assessment and Assurance (QAA) meetings discuss a number of topics from falls, pandemic assessment and control, infections, resident skin and weight issues, but lacked system to analysis outcomes. The facility's Quality Assurance and Performance Improvement (QAPI/QAA) policy, dated July 2017, documented the QAPI focuses on systems and processes. The organization sets goals for performance and measures progress toward those goals. Aspects of service and care are measured against established performance goals. Key monitors are measured and trended on a quarterly basis. The policy further documented the scope of the QAPI program encompasses all segments of the facility including resident/family feedback, staff satisfaction, individualized resident care plans, information technology, facility and maintenance plans and QAPI. The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan. This failure had the ability to affect all residents in the facility.