The facility identified a census of 23 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to fully complete the Comprehensive Minimum Data Set (MDS) for Resident (R) 3 when staff did not complete an analysis for triggered Care Area Assessments (CAA). This placed this resident at risk for an inaccurate plan of care and unidentified care needs. Findings included: - R3's Electronic Medical Record (EMR) documented diagnoses of mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), dementia (a progressive mental disorder characterized by failing memory and confusion), weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hemiplegia (paralysis of one side of the body), hypertension (HTN-elevated blood pressure), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R3's Quarterly MDS dated 07/07/24 documented a Brief Interview for Mental Status (BIMS) score of zero which indicated a severely impaired cognition. R3 had impairment on both sides of his upper and lower extremities. R3 required the use of a Broda chair (specialized wheelchair with the ability to tilt and recline) for mobility. R3 was dependent on staff for all functional abilities. R3 was always incontinent of bowel and bladder. R3 required enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). R3's Care Area Assessment (CAA) dated 01/20/24 triggered for cognitive loss/dementia, communication, urinary incontinence, psychotropic (alerts mood or thought) drug use, visual function, dehydration/fluid maintenance, feeding tube (tube for introducing high-calorie fluids into the stomach), pressure ulcer, pain, nutritional status, and dental care. All triggered CAA lacked completion with analysis of findings. R3's Care Plan revised on 04/17/23 documented that staff would provide care to R3 to maintain appearance, hygiene, and skin integrity. R3's plan of care documented R3 received meals via percutaneous endoscope gastrostomy (PEG-a tube inserted through the wall of the abdomen directly into the stomach). R3's plan of care documented she was incontinent of bowel and bladder. On 10/30/24 at 09:34 AM R3 was reclined in her Broda chair, with her eyes shut. On 10/31/24 at 12:08 PM Administrative Nurse D stated she was unaware the CAA needed to be filled out. She stated she was told they were optional and only needed to be filled out if she needed to use them for the care plan. She stated she had been doing the MDS for three years and had just received training. She stated she had learned each triggered CAA needed resident analysis documentation. The updated facility Comprehensive Assessment policy reviewed 02/2019 documented the facility would conduct initial and periodic comprehensive, accurate, standardized, reproducible assessments of each resident's function capacity. The assessment process would include direct observation and communication with the resident and responsible party and family, as well as communication with licensed and non-licensed direct care staff members from all departments on all shifts. The resident assessment instrument (RAI) system developed by the federal government would be used as the basis for the assessment, care planning, and documentation system. The facility failed to ensure staff fully completed the Comprehensive MDS for R3 when staff did not complete the triggered CAA. This placed R3 at risk for an inaccurate plan of care and unidentified care needs.

The facility identified a census of 23 residents. The sample included 12 residents with six residents reviewed for falls and accidents. Based on observation, record review, and interviews, the facility failed to consistently implement interventions to prevent falls for Resident (R)19 who had multiple falls. This deficient practice placed R19 at risk for further falls and related injuries. Findings included: - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented restlessness and agitation, frontotemporal neurocognitive disorder (a group of disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost), and pain. The Quarterly Minimum Data Set (MDS) for R19 dated 09/07/24 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R19 had two falls since admission with no evidence of injury and two falls with injury, skin tears, abrasions, and bruising. The MDS documented that R19 was dependent on staff for bathing, toileting, and dressing. R19's Falls Care Area Assessment dated 03/14/24 documented that staff were to monitor R19's wandering and assist him with walking. Staff were to walk alongside him in times of wandering. Staff were to accompany R19 to all areas and ensure his needs were met. Nursing was to implement fall precautions and follow facility fall protocol. R19's Care Plan dated 03/14/24 documented R19 was a fall risk related to his wandering and stated a goal that he would not sustain serious injury throughout his stay. Staff were to ensure R19's call light was always near him, while he was in his room. Staff was to provide a low-stimulation environment, follow facility fall protocol, and keep the tray table away from R19's path when staff were not supervising. R19's plan of care dated 07/15/24 documented R19's family and hospice provider agreed to stop doing neurological assessments and vital sign checks after falls, related to R19's increased agitations. R19's plan of care dated 09/09/24 documented that staff were to be one-to-one with R19 when he was walking. Staff were to ensure a fall-hazard-free environment, adequate lighting, and proper footwear. The plan directed to make sure there were no trip hazards, ensure the floor was clean and dry, and ensure R19's blankets were not wrapped tightly around his lower extremities while he was in bed. R19's EMR under Nursing Notes documented non-injury falls on 08/26/24, 09/02/24, 09/08/24, 09/14/24, 09/26, 10/15, and 10/18/24. R19's EMR under Nursing Note dated 9/02/24 documented that a nurse was assisting R19 in his room, and R19 was settled sitting back on his bed. The nurse left the room to complete a treatment across the hall, as they exited the treatment room, the resident was heard groaning. The nurse entered the room to find the resident lying on the floor with his head on the trash can. R19 had a blanket and shoes on, his call light was within reach. R19 did not have a visible injury. Staff lifted R19 and put him back on the bed. R19's clinical record lacked evidence an intervention was implemented in response to the 09/02/24 fall. R19's EMR under Nursing Note dated 9/05/24 documented that R19 was found on the floor. He was relaxed and appeared to have no signs of pain or distress. He was wearing blankets around his back and was resting his back against the wall and headboard. Staff used a Hoyer (total body mechanical lift) to lift R19 into the bed. R19 had been aggressive during position changes due to advanced dementia. R19 also demonstrated poor awareness. Due to R19's dementia, the resident was unable to communicate complex thoughts, though he showed his expressions well, and when he was frustrated, he became visibly agitated and aggressive to staff. R19's family requested orders not to attempt to obtain vital signs if the resident was agitated or aggressive. R19's clinical record lacked evidence an intervention was implemented in response to the 09/05/24 fall. R19's EMR under Nursing Note dated 9/14/24 documented that R19 was found on the floor. He was sitting on the floor in front of his chair, had his left arm bent behind him, his back leaning against the right front of the chair, with his left back against the chair. The resident did not show any signs of distress. The Certified Nurse Aide (CNA) suggested that he slid off the chair and stated R19 was sitting in the chair before his fall. Staff performed range of motion with no apparent signs of pain. Staff assisted R19 to a standing position and he did not show any signs of pain with weight bearing. R19's clinical record lacked evidence an intervention was implemented in response to the 09/12/24 fall. R19's EMR under Nursing Note dated 9/26/24 documented R19 was found lying on his left side in front of his recliner in his room. The CNA staff reported they had assisted R19 with incontinence care as he had a bowel movement. R19 was resistive during care, at some point, he got himself up from his bed and fell. An initial assessment showed no signs of major injury other than a 0.5-centimeter (cm) skin tear to the left elbow. R19 did not want to sit after his fall so he was assisted to sit out on the patio with staff and was taken for a short walk. R19's clinical record lacked evidence an intervention was implemented in response to the 09/26/24 fall. R19's EMR under Nursing Notes dated 10/15/24 documented that R19 had an unwitnessed fall in his room. He was sitting upright in front of the closet door. Staff assessed and noted there were no signs of injury. Staff obtained R19's vital signs, and all vital signs were within his normal baseline. The note documented staff spoke to the hospice nurse concerning the fall. R19's clinical record lacked evidence an intervention was implemented in response to the 10/15/24 fall. R19's EMR under Nursing Notes dated 10/18/24 documented the nurse was called to R19's room. The CNA staff reported that they heard R19 yelling and upon entering R19's room, he was on the floor. R19 lay on his left side, with his head angled towards the window and closet corner. His feet were in the direction of the door. Staff provided comfort and R19 was not yelling when the nurse entered his room. Staff assisted R19 to stand and he became agitated, which was his baseline. The note documented R19 was more agitated than usual, likely from generalized pain from the fall and the need for the nurse to approximate skin tears. R19 seemed to want to wander; he was assisted to his wheelchair and staff wheeled him around, which tended to provide R19 some comfort. R19's clinical record lacked evidence an intervention was implemented in response to the 10/18/24 fall. On 10/29/24 at 09:07 AM R19 sat in the chair in his room with a pillow behind him, covered with a blanket. On 10/30/24 at 09:42 AM R19 sat in the chair in his room. His breakfast tray sat on the TV stand in front of him. On 10/31/24 at 11:24 AM Licensed Nurse (LN) G stated an intervention was put in place anytime a resident had a fall. She stated if an intervention was not put in at the time of the fall, staff would add one after stand-up or after a team huddle. On 10/31/24 at 11:53 AM, CNA M stated fall interventions could be viewed on the resident's care plan. She stated the CNA and the nurses would have a team huddle after a resident fell and decide on an intervention as a team. On 10/31/24 at 12:08 PM Administrative Nurse D stated the nurse on duty should implement a fall intervention after a team huddle. She stated if the nurse was unsure what intervention should be implemented, the nurse should add to the care plan that they would call the director for ideas. On 10/31/24 at 12:11 PM Administrative Nurse A stated the facility had been working on interventions for R19's falls. Administrative Nurse A stated the facility had a performance improvement project (PIP) dated 09/09/24 started. Administrative Nurse A stated the facility would continue working with family and staff on fall interventions. The facility's Accident and Incident Documentation documented that when an elder experiences an incident or accident, the nurses caring for the elder would record the elder's response for at least 72 hours or until the elder's condition was stabilized. The elder's physician or designated physician would be informed of the incident or accident. The information provided to the physician would be recorded in the interdisciplinary notes. The facility failed to identify and implement interventions to prevent further falls for R19. This deficient practice placed R19 at risk for further falls and related injuries.

The facility identified a census of 23 residents. The sample included 12 residents with one resident reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R) 19. This deficient practice placed R19 at risk for impaired end-of-life care. Findings Included: - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of documented restlessness and agitation, frontotemporal neurocognitive disorder (a group of disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost), and pain. The Quarterly Minimum Data Set (MDS) for R19 dated 09/07/24 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R19 was dependent on staff for bathing, toileting, and dressing. The MDS documented that R19 received hospice services during the observation period. R19's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/13/24 documented the resident was on hospice, related to cognitive loss and dementia (a progressive mental disorder characterized by failing memory and confusion). The CAA documented that R19's plan of care would include ways to provide support and comfort to R19, decrease his agitation and anxiety, and provide comforting activities that the resident enjoys. R19 was unable to answer assessment questions appropriately. R19 becomes easily agitated and cannot follow prompts for answers related to advanced dementia. R19's Care Plan dated 03/12/24 documented R19 had a terminal prognosis related to dementia and was receiving hospice services. Staff were to administer medications for anxiety and comfort as ordered. Staff were to allow R19 and his family to share worries, concerns, and feelings. The facility would arrange time for spiritual and religious practice. Staff were to contact hospice and family upon observed changes. Staff was to encourage visitors and encourage R19 to interact with visitors and other residents as much as possible. Hospice was to provide bathing, oral care, peri-care, companionship, and family support. Staff was to observe R19 closely for signs of pain, administer pain medications as ordered, and notify the physician immediately if there is breakthrough pain. Staff were to see the hospice calendar in R19's binder at the nurse's station for the hospice visit schedule. Nursing was to contact hospice if R19 needed additional visits or supplies. The care plan lacked contact information for the hospice provider and lacked information regarding the frequency of visits, the supplies, equipment, and medications provided by the hospice. A review of the hospice-provided binder revealed that R19 was admitted to hospice services on 03/05/24. On 10/29/24 at 09:07 AM R19 sat in the chair in his room, with a pillow behind him, covered with a blanket. On 10/31/24 at 11:24 AM Licensed Nurse (LN) G stated there should be collaboration of care between the facility and hospice and said staff should be able to open the resident's care plan and know what the hospice provider provides for the resident, and what the facility provides for the resident. On 10/31/24 at 11:53 AM Certified Nursing Aide (CNA) M stated if she needed to know when the nurse or aide for a resident on hospice was going to be at the facility, she would find that information in the resident's hospice binder. She stated she was unsure what supplies the hospice provided, or what equipment. CNA M stated she would ask her charge nurse. On 10/31/24 at 12:08 PM Administrated Nurse D stated that administrative staff know what equipment each hospice resident has. She stated if the resident ran out of hospice supplies, the resident would just use the facility's supplies. Administrative Nurse D said she was unsure what medications should be part of the care plan. The facility's Hospice Services policy documents each resident will receive, and this facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility provides continuity of care to provide residents who are terminally ill with the opportunity to receive comprehensive, interdisciplinary care that recognizes their spiritual needs and to assist residents, family members, and friends to live as fully and completely as possible with meaning and dignity. Residents and family members and friends may be offered hospice care upon request of the resident and families and or guardians to meet care and services needs which is consistent with the expressed preferences of the resident's family members and or guardians. The facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for R19. This deficient practice placed R19 at risk for impaired end-of-life care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 19 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered intervention for behaviors for one sampled resident, Resident (R) 19. This placed the resident at risk for injury and unmet needs. Findings included: - The Electronic Medical Record (EMR) documented R19 had diagnoses of late onset Alzheimer dementia without behavioral disturbance (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The admission Minimum Data Set Assessment (MDS), dated [DATE], documented R19 had severely impaired cognition and required supervision and set up assistance for dressing, toileting, and independent with bed mobility, transfers, ambulation, eating, and personal hygiene. The assessment further documented R19 wandered four to six days, had no behaviors, and did not take any medications. The Quarterly MDS, dated 05/20/23, documented R19 had long and short-term memory problems and was independent with all activities of daily living (ADLs). R19 had disorganized thinking, hallucinations (perception of something not present), delusions (unshakable belief in something that's untrue), wandered one to three days, and had rejection of care four to six days. The MDS further documented R19 received antidepressant and antianxiety medication. The Care Plan, dated 05/31/23, directed staff to encourage R19 to participate in group activities, spend one on one time in the [NAME] to provide reorientation and comfort; administer medication as ordered. The plan directed to offer R19 puzzle or books appropriate to her cognition level, and take outside for a walk or to the patio when she felt anxious. The care plan lacked interventions to address specific behaviors, fears and/or triggers and lacked resident specific interventions to address those items. The Physician's Order, dated 04/21/23, directed staff to administer fluoxetine hci ,(an antidepressant medication) 20 milligrams (mg), by mouth, daily for depression. The medication was discontinued on 05/17/23. The Physician's Order, dated 05/07/23, directed staff to administer Xanax, (an antianxiety medication), by mouth every eight hours, three times per day, for the diagnosis of anxiety. The medication was discontinued on 05/09/23. The Physician's Order, dated 05/09/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice a day, as needed, for the diagnosis of anxiety. The medication was discontinued on 05/30/23. The Physician's Order, dated 05/30/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice per day, as needed, for the diagnosis of anxiety. The order lacked a stop date for the as needed medication. The Nurse's Note, dated 04/19/23 at 10:30 PM, documented R19 packed up some belongings and tried to leave out of the south door. The note further documented a Wanderguard (a monitoring device used to help ensure safety) was placed on her right wrist. The Nurse's Note, dated 04/25/23 at 12:30 AM, documented R19 stated that there were men threatening to kill people and staff reassured the resident that the doors to the facility were locked. The Nurse's Note, dated 05/02/23 at 09:30 AM, documented R19 would not answer to her name and told staff she had a different name, and she was little. The Nurse's Note, dated 05/03/23 at 08:07 PM, documented R19 was tearful, and did not to shower. The note further documented R19 cried throughout the shower and became aggressive with the Certified Nurse Aide (CNA) who tried to get her dressed. R19 stated she would not put clothes on because the CNA took her clothes off and swung at the resident. Staff offered R19 reassurance. The Nurse's Note, dated 05/13/23 at 09:39 AM, documented R19 reported she was in lockdown because there dangerous people in the facility. The resident used derogatory racial slurs as well. in the facility who was eating his own children. Reassurance given by staff. The Nurse's Note, dated 05/13/23 at 08:01 PM, documented staff heard the resident crying in her room and found her squatted down on her hands and feet, underneath her bedside table. The note further documented R19 tried to pick up a bucket of candy that fell to the floor and asked the nurse for assistance. While the nurse attempted to assist her, R19 grabbed the nurse's arm, dug her fingernails in the arm, scraping and breaking the skin. The note documented the nurse was able to remove her arm from the resident's grasp, finish cleaning up the candy, and sat in a chair across the room from R19. R19, who was still on the floor with her back against the bed began to scream for help. R19 screamed at the nurse and as the nurse tried to explain what happened, R19 called the nurse a liar and proceeded to try to slam her walker into the nurse. R19 threw two shoes, a bottle of lotion, a book and her hose at the nurse. R19 stated, As soon as I find my gun, I will shoot you! The nurse attempted to reorient R19 and tried to redirect her without success and refused to allow the nurse to assist her off the floor. The note documented the nurse left the room and returned with another staff member to assist R19 off the floor. As staff attempted to transfer R19 to her bed, she was extremely combative , hit, scratched, and pinched staff. The note documented staff checked on R19 multiple times over the next half hour and as staff checked on her, she would move her walker to the door and not allow anyone in. Staff had to go through another resident's room, through the bathroom to R19's room, to check on the resident. The Nurse's Note, dated 05/13/23 at 09:11 PM, documented R19 continued to barricade herself in her room and not allow anyone to enter. The note further documented R19 would curse and shout at someone she saw in her room that was not there. Staff would check on the resident through the bathroom door and she stated a black man tried to kill her. The Nurse's Note, dated 05/16/23 at 01:55 AM, documented R19 self-barricaded herself in her room and would not let the staff enter her room. The note documented staff went through another resident's room, through the bathroom, so they could check on the resident. The nurse went back to R19's room after 30 minutes, knocked on her room door and asked R19 if she could come in. R19 let the nurse in and started to talk about the big black man and that the sheriff was looking for him. The nurse told R19 that she thought the sheriff had caught the man and was able to assist R19 to bed. The Nurse's Note, dated 05/17/23 at 08:41 AM, documented R19's mental trauma and anguish was a major issue and R19 had refused to leave her room for breakfast as R19 thought the facility was in lockdown. Staff reassured her that all the doors were locked, and no one was inside that should not be. The Nurse's Note, dated 05/17/23 at 03:57 PM, documented R19 barricaded her door with her walker and told staff that there was a black man who had tried to get into her room and staff had to go through another resident room to check on her. The Nurse's Note, dated 05/17/23 at 06:44 PM, documented R19 refused to eat and stated a large black man was loose in the community; he had ate his children's fingers and R19 thought he had been to her room twice that evening. Reassurance was given to the resident. The Nurse's Note, dated 05/18/23 at 04:59 AM, documented R19 was tearful and stated, My mom and dad don't want me. Reassurance was given to the resident. The Nurse's Note, dated 05/22/23 at 10:53 PM, documented R19 barricaded herself in her room as she thought there was a criminal loose and thought he tried to get into her room. The Nurse's Note, dated 05/26/23 at 10:49 PM, documented R19 barricaded herself in her room and refused all care and assistance. The Nurse's Note, dated 05/27/23 at 09:10 PM, documented R19 refused dinner and believed that something dangerous was going to happen so she blocked her room door. The Nurse's Note, dated 05/28/23 at 05:35 PM, documented R19 believed she was married to the physician, refused all medications, threw her dinner tray at staff, and called staff a derogatory name. The Care Plan Note, dated 05/31/23 at 01:27 PM, documented R19's family had concern related to her behaviors and delusions and stated R19 had times of sundowning at home but had never had the behaviors and aggression she was exhibiting now. The note further documented that family felt her behaviors had improved since treatment for recent heath issues were finished and agreed that arranging a mental health appointment was a good idea. The Nurse's Note, dated 06/07/23 at 11:08 PM, documented R19 believed her son called her to tell her that he no longer wanted anything to do with her, refused her shower, and would not let staff change her bedding as there was a small spot of bowel movement on it. The Nurse's Note, dated 06/11/23 at 11:00 AM, documented R19 continued to voice paranoia about people hiding secretly in rooms and behind doors. The Nurse's Note, dated 06/15/23 at 11:41 AM, documented R19 became increasingly irritable and had increased paranoia that something bad was going to happen. R19's EMR lacked evidence mental health support services were provided to R19. On 06/14/23 at 08:00 AM, observation revealed R19 eating breakfast in the dining room conversing with her tablemate's. On 06/15/23 at 01:45 PM, Certified Nurse Aide -- stated R19 cussed at staff and they would go through the bathroom to check on the resident. CNA M further stated they received dementia computer training and through inservices. On 06/15/23 at 02:45 PM, Certified Medication Aide (CMA) R stated R19 had a lot of behaviors and when she got agitated, she barricaded herself in her room. CMA R further stated she snuck into the bathroom through an adjoining room to check on R19. On 06/15/23 at 03:00 PM, Licensed Nurse (LN) H stated R19 had days that she was happy and other days she was paranoid, often barricading herself in her room when she thought there was a criminal loose. LN H further stated R19's family was very supportive and come to the facility to assist staff when needed. On 06/19/23 at 10:34 AM, Administrative Nurse D verified the care plan lacked interventions to address specific behaviors and lacked resident specific interventions to address those. The facility's Care Plan Revisions policy, dated 11/16, documented the care plan would be revised whenever the behavior or cognition of a resident changed with either a deterioration or an improvement. The care plan would include specific individualized instructions to staff with interventions to meet the unmet needs of the resident . The facility failed to revise the care plan for R19, who had behaviors. This placed the resident at risk for injury and unmet needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 19 residents. The sample included eight residents, with three reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for Resident (R) 19, who had dementia related behaviors. This placed the resident at risk for decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R19 had diagnoses of late onset Alzheimer dementia without behavioral disturbance (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The admission Minimum Data Set Assessment (MDS), dated [DATE], documented R19 had severely impaired cognition and required supervision and set up assistance for dressing, toileting, and independent with bed mobility, transfers, ambulation, eating, and personal hygiene. The assessment further documented R19 wandered four to six days, had no behaviors, and did not take any medications. The Quarterly MDS, dated 05/20/23, documented R19 had long and short-term memory problems and was independent with all activities of daily living (ADLs). R19 had disorganized thinking, hallucinations (perception of something not present), delusions (unshakable belief in something that's untrue), wandered one to three days, and had rejection of care four to six days. The MDS further documented R19 received antidepressant and antianxiety medication. The Care Plan, dated 05/31/23, directed staff to encourage R19 to participate in group activities, spend one on one time in the [NAME] to provide reorientation and comfort; administer medication as ordered. The plan directed to offer R19 puzzle or books appropriate to her cognition level, and take outside for a walk or to the patio when she felt anxious. The care plan lacked interventions to address specific behaviors, fears and/or triggers and lacked resident specific interventions to address those items. The Physician's Order, dated 04/21/23, directed staff to administer fluoxetine hci ,(an antidepressant medication) 20 milligrams (mg), by mouth, daily for depression. The medication was discontinued on 05/17/23. The Physician's Order, dated 05/07/23, directed staff to administer Xanax, (an antianxiety medication), by mouth every eight hours, three times per day, for the diagnosis of anxiety. The medication was discontinued on 05/09/23. The Physician's Order, dated 05/09/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice a day, as needed, for the diagnosis of anxiety. The medication was discontinued on 05/30/23. The Physician's Order, dated 05/30/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice per day, as needed, for the diagnosis of anxiety. The order lacked a stop date for the as needed medication. The Nurse's Note, dated 04/19/23 at 10:30 PM, documented R19 packed up some belongings and tried to leave out of the south door. The note further documented a Wanderguard (a monitoring device used to help ensure safety) was placed on her right wrist. The Nurse's Note, dated 04/25/23 at 12:30 AM, documented R19 stated that there were men threatening to kill people and staff reassured the resident that the doors to the facility were locked. The Nurse's Note, dated 05/02/23 at 09:30 AM, documented R19 would not answer to her name and told staff she had a different name, and she was little. The Nurse's Note, dated 05/03/23 at 08:07 PM, documented R19 was tearful, and did not to shower. The note further documented R19 cried throughout the shower and became aggressive with the Certified Nurse Aide (CNA) who tried to get her dressed. R19 stated she would not put clothes on because the CNA took her clothes off and swung at the resident. Staff offered R19 reassurance. The Nurse's Note, dated 05/13/23 at 09:39 AM, documented R19 reported she was in lockdown because there dangerous people in the facility. The resident used derogatory racial slurs as well. in the facility who was eating his own children. Reassurance given by staff. The Nurse's Note, dated 05/13/23 at 08:01 PM, documented staff heard the resident crying in her room and found her squatted down on her hands and feet, underneath her bedside table. The note further documented R19 tried to pick up a bucket of candy that fell to the floor and asked the nurse for assistance. While the nurse attempted to assist her, R19 grabbed the nurse's arm, dug her fingernails in the arm, scraping and breaking the skin. The note documented the nurse was able to remove her arm from the resident's grasp, finish cleaning up the candy, and sat in a chair across the room from R19. R19, who was still on the floor with her back against the bed began to scream for help. R19 screamed at the nurseand as the nurse tried to explain what happened, R19 called the nurse a liar and proceeded to try to slam her walker into the nurse. R19 threw two shoes, a bottle of lotion, a book and her hose at the nurse. R19 stated, As soon as I find my gun, I will shoot you! The nurse attempted to reorient R19 and tried to redirect her without success and refused to allow the nurse to assist her off the floor. The note documented the nurse left the room and returned with another staff member to assist R19 off the floor. As staff attempted to transfer R19 to her bed, she was extremely combative , hit, scratched, and pinched staff. The note documented staff checked on R19 multiple times over the next half hour and as staff checked on her, she would move her walker to the door and not allow anyone in. Staff had to go through another resident's room, through the bathroom to R19's room, to check on the resident. The Nurse's Note, dated 05/13/23 at 09:11 PM, documented R19 continued to barricade herself in her room and not allow anyone to enter. The note further documented R19 would curse and shout at someone she saw in her room that was not there. Staff would check on the resident through the bathroom door and she stated a black man tried to kill her. The Nurse's Note, dated 05/16/23 at 01:55 AM, documented R19 self-barricaded herself in her room and would not let the staff enter her room. The note documented staff went through another resident's room, through the bathroom, so they could check on the resident. The nurse went back to R19's room after 30 minutes, knocked on her room door and asked R19 if she could come in. R19 let the nurse in and started to talk about the big black man and that the sheriff was looking for him. The nurse told R19 that she thought the sheriff had caught the man and was able to assist R19 to bed. The Nurse's Note, dated 05/17/23 at 08:41 AM, documented R19's mental trauma and anguish was a major issue and R19 had refused to leave her room for breakfast as R19 thought the facility was in lockdown. Staff reassured her that all the doors were locked, and no one was inside that should not be. The Nurse's Note, dated 05/17/23 at 03:57 PM, documented R19 barricaded her door with her walker and told staff that there was a black man who had tried to get into her room and staff had to go through another resident room to check on her. The Nurse's Note, dated 05/17/23 at 06:44 PM, documented R19 refused to eat and stated a large black man was loose in the community; he had ate his children's fingers and R19 thought he had been to her room twice that evening. Reassurance was given to the resident. The Nurse's Note, dated 05/18/23 at 04:59 AM, documented R19 was tearful and stated, My mom and dad don't want me. Reassurance was given to the resident. The Nurse's Note, dated 05/22/23 at 10:53 PM, documented R19 barricaded herself in her room as she thought there was a criminal loose and thought he tried to get into her room. The Nurse's Note, dated 05/26/23 at 10:49 PM, documented R19 barricaded herself in her room and refused all care and assistance. The Nurse's Note, dated 05/27/23 at 09:10 PM, documented R19 refused dinner and believed that something dangerous was going to happen so she blocked her room door. The Nurse's Note, dated 05/28/23 at 05:35 PM, documented R19 believed she was married to the physician, refused all medications, threw her dinner tray at staff, and called staff a derogatory name. The Care Plan Note, dated 05/31/23 at 01:27 PM, documented R19's family had concern related to her behaviors and delusions and stated R19 had times of sundowning at home but had never had the behaviors and aggression she was exhibiting now. The note further documented that family felt her behaviors had improved since treatment for recent heath issues were finished and agreed that arranging a mental health appointment was a good idea. The Nurse's Note, dated 06/07/23 at 11:08 PM, documented R19 believed her son called her to tell her that he no longer wanted anything to do with her, refused her shower, and would not let staff change her bedding as there was a small spot of bowel movement on it. The Nurse's Note, dated 06/11/23 at 11:00 AM, documented R19 continued to voice paranoia about people hiding secretly in rooms and behind doors. The Nurse's Note, dated 06/15/23 at 11:41 AM, documented R19 became increasingly irritable and had increased paranoia that something bad was going to happen. R19's EMR lacked evidence mental health support services were provided to R19. On 06/14/23 at 08:00 AM, observation revealed R19 eating breakfast in the dining room conversing with her tablemate's. On 06/15/23 at 01:45 PM, Certified Nurse Aide -- stated R19 cussed at staff and they would go through the bathroom to check on the resident. CNA M further stated they received dementia computer training and through inservices. On 06/15/23 at 02:45 PM, Certified Medication Aide (CMA) R stated R19 had a lot of behaviors and when she got agitated, she barricaded herself in her room. CMA R further stated she snuck into the bathroom through an adjoining room to check on R19. On 06/15/23 at 03:00 PM, Licensed Nurse (LN) H stated R19 had days that she was happy and other days she was paranoid, often barricading herself in her room when she thought there was a criminal loose. LN H further stated R19's family was very supportive and come to the facility to assist staff when needed. On 06/19/23 at 10:34 AM, Administrative Nurse D stated R19 had been having other health issues at the times that she was having the behaviors and R19's physician tried to manage those behaviors with medication. Administrative Nurse D further stated they had wanted to wait to seek mental health support after her health issues were taken care of and had the support of the family to wait. The facility's Dementia and Behavior Management policy, dated 03/20/23, documented all staff would be educated on appropriate dementia care and dealing with difficult behaviors prior to working with elders with dementia, at least annually and as determined to be necessary by the nursing supervisor. Training would be documented in the staff member's personnel record. All behaviors related to all types of dementia would be monitored and documented for the purpose of tracking and trending those behaviors. The development of person-centered individualized dementia care plan programming for each resident and Identification of triggers of specific behaviors to assist staff members to avoid these triggers of unmet needs which the resident was unable to verbalize or communicated, evaluate current behavior management programming intervention. The nurse will report pertinent findings from the behavior assessment to the physician and representative as appropriate. The facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for R19, who had dementia related behaviors. This placed the resident at risk for decreased quality of life.

The facility had a census of 19 resident. The sample included eight residents. Based on observation, record review, and interview, the facility failed to ensure the facility had a system in place to acknowledge and address the Consultant Pharmacist's (CP) recommendations for Resident (R)10, which placed the resident at risk of impaired health. Findings included: - R10's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), peripheral vascular (abnormal condition affecting the blood vessels) disease, dementia (progressive mental disorder characterized by failing memory, confusion), mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), kidney failure, atrial fibrillation (rapid, irregular heart beat), and history of urinary tract infection, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (elevated blood pressure), and malignant neoplasm (cancer) of breast. The Quarterly Minimum Data Set, dated 06/03/23, documented R10 had moderately impaired cognition, dependent of one or two staff with activities of daily living, had scheduled pain medication, no ulcers, and received insulin. The Nutrition Care Plan, dated 06/13/23, documented R10 had an alteration in nutrition related to diabetes and dementia (initiated 08/17/18). The care plan directed staff to obtain lab per or of physician ordered. On 10/10/17, the Physician Order directed a Basic Metabolic Panel (BMP- a test that measures eight different substances in blood) and Hemoglobin A1C (HgbA1c)-blood test that measures average blood sugar levels over the past three months) every six months related to hypertension, diabetes mellitus due to underlying condition with diabetic neuropathy (dysfunction of nerves typically causing numbness ad weakness). The Pharmacy Consultant Review, dated 01/03/23, recorded R10 had orders for HgbA1c every six months, but no results on file in over a year. The recommendation requested to ensure all labs were drawn and reported in the chart as ordered. The Pharmacy Consultant Review, dated 05/02/23, documented R10 had no lab results on file in the past year despite orders for a quarterly BMP and HgbA1c every six months. The recommendation requested a complete blood count (CBC-lab test to that provide information about cells in a person's blood), a complete metabolic panel (CMP-test for chemical balance and metabolism), and HgbA1c at that time. The Pharmacist Consultant Review, dated 06/02/23, documented R10 had no lab results on file in the past year despite orders on file in recent weeks to get these updated. The recommendation requested the facility to ensure all labs were drawn and reported in chart. The EMR recorded a BMP on 04/11/22, a general chemistry (group of tests ordered to determine general health status) on 05/23/22. The EMR lacked a six-month BMP and HGbA1c as ordered. R10's EMR lacked evidence the CP recommendations were addressed by staff or physician. On 06/14/23 at 08:00 AM, observation revealed R10 sat in the dining room, in a high-backed wheelchair eating her breakfast. On 06/19/23 at 10:12 AM, Administrative Nurse D, reported R10's lab work orders were clarified in 05/2023. Administrative Nurse D verified the lack of response to the CP regarding the missing BMP and HGbA1c at six-month interval. The facility's Consultant Pharmacist Service Provider Requirements policy, dated 06/02/16 documented a review of the medication regimen of each resident monthly, utilizing federally mandated standards of care in addition to other applicable standards and document the review findings in the resident's medical record. Pharmacist will email the report to the DON/ADON for review. The recommendations will be sent to the provider for consideration. The facility failed to ensure the facility had a system in place to acknowledge and address the CP recommendations to obtain ordered laboratory blood test as ordered by the physician for R10, which placed the resident at risk of impaired health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 19 residents. The sample included eight residents, with six reviewed for unnecessary medications, Based on observation, record review, and interview, the facility failed to administer as needed clonidine (high blood pressure medication) for Resident (R) 9, who had systolic blood pressure (SBP-the maximum pressure the heart exerts while beating) above physician ordered parameters. This placed the resident at risk for physical decline and complications related to high blood pressure. Findings included: - The Electronic Medical Record (EMR) documented R9 had diagnoses of hypertension (high blood pressure), systolic heart failure (the heart muscle is weak and cannot contract normally), and diastolic heart failure (the heart muscle is stiff and cannot relax normally). The Annual Minimum Data Set Assessment (MDS), dated [DATE], documented R9 had intact cognition and was independent with all activities of daily living (ADLs). The assessment further documented R9 received seven days of a diuretic (medication to promote the formation and excretion of urine) during the lookback period. The Quarterly MDS, date 03/24/23, documented R9 had intact cognition and was dependent upon two staff for bed mobility, transfers, required extensive assistance of one staff for dressing, toileting, personal hygiene. R9 did not ambulate. The assessment further documented R9 received seven days of a diuretic during the lookback period. The Care Plan, dated 04/27/23, directed staff to administer medications as ordered, monitor R9's blood pressure according to standing parameters. The plan directed staff to encourage R9 to not ambulate or transfer independently and call for assistance if she felt dizzy; and observe for signs and symptoms of hypotension (low blood pressure) after administration of blood pressure medications and dizziness. The Physician's Order, dated 12/25/21, directed staff to administer losartan potassium (blood pressure medication) 100 milligrams (mg), by mouth, and hold if her systolic blood pressure was less than 110. The Physician's Order, dated 01/18/23, directed staff to administer clonidine, 0.1 mg, by mouth, as needed, if R9's systolic blood pressure was greater than 170 for the diagnosis of hypertension. The Physician's Order, dated 01/25/23, directed staff to administer Norvasc (blood pressure medication), 10 mg, by mouth at bedtime for the diagnosis of chronic combined systolic and diastolic heart failure. The Medication Administration Record (MAR) for March 2023 documented R9's systolic blood pressure was out of parameters and lacked documentation she received the as needed clonidine medication the following days: 03/02/23 at bedtime for the blood pressure of 175/57 millimeters (mm) of Mercury (Hg) 03/04/23 in the am for the blood pressure of 178/88 mmHg 03/08/23 at bedtime for the blood pressure of 174/89 mmHg 03/09/23 in the afternoon blood pressure of 186/86 mmHg 03/12/23 in the afternoon for the blood pressure of 171/88 mmHg 03/19/23 in the afternoon for the blood pressure of 173/93 mmHg The MAR for April 2023 documented R9's systolic blood pressure was out of parameters and lacked documentation she received the as needed clonidine medication the following days: 04/14/23 in the afternoon for the blood pressure of 192/93 mmHg 04/23/23 in the morning for the blood pressure of 172/87 mmHg The MAR for June 2023 documented R9's systolic blood pressure was out of parameters and lacked documentation she received the as needed clonidine medication the following days: 06/17/23 in the afternoon for the blood pressure of 172/70 mmHg On 06/14/23 at 03:48 PM, observation revealed R9 ambulated independently in her room. On 06/14/23 at 04:00 PM, Administrative Nurse D stated she felt the medication was given correctly and that the documentation was incorrect and confusing. On 06/14/23 at 04:12 PM, Licensed Nurse (LN) G stated R9's blood pressure was taken three times per day and if her systolic blood pressure was over 170, staff administered the clonidine. The facility's Physician Orders for Medications and Treatments policy, dated 05/2019, documented all medications would be administered as ordered by a health care professional authorized by the state to order medications. The facility failed to administer as needed clonidine to R9, as directed by the physician, when R9's SBP exceeded the ordered parameters., This placed R9 at risk for physical decline and complications related to high blood pressures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 19 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to attempt or address Resident (R)17's antipsychotic (mood altering medication) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications for a gradual dose reduction (GDR). The facility further failed to ensure R19's as needed antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication had a stop date as required This deficient practice placed R17 and R19 at risk for adverse side effects related to psychotropic (alters mood or thought) medication use. Findings included: - R17's Electronic Medical Record (EMR) recorded diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear)disorder, chronic kidney disease, seizures (violent involuntary series of contractions of a group of muscles), hypertension (elevated blood pressure) and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had moderate cognitive impairment. R17 had no delirium, psychosis, or behaviors. The MDS further documented R17 had non-traumatic brain dysfunction, Alzheimer's disease, anxiety disorder and depression. R17 took an antidepressant and an antipsychotic which had been received on a routine basis only, with no GDR or physician documentation of the GDR as clinically contraindicated. The Psychotropic Drug Use Care Area Assessment, dated 10/19/22, documented staff administered medication as ordered, monitor medication side effects and consult with the physician for GDR recommendations. The Care Plan, revision dated 04/18/23, documented R17 had a diagnosis of anxiety and depression and used the psychotropic medications paroxetine (antidepressant) and Abilify (antipsychotic). The care plain directed staff to administer medications as ordered, monitor for side effects, and consult with pharmacy, and the physician to consider dosage reduction when clinically at least quarterly. The Physician Order Sheet (POS), dated 05/04/23, directed staff to administer Abilify 2 milligrams (mg) one time a day (start date of 10/12/22) and paroxetine 30 mg one time a day (start date of 03/07/23). The Pharmacy Consultation Review, dated 04/03/23, documented R17 received Abilify 2 mg and paroxetine 30 mg daily since October; all agents with psychoactive properties fell under gradual dose reduction guidelines. The review further documented to consider a trial reduction to at least one of these agents if clinically appropriate. R17's EMR lacked evidence of a GRD or a response which documented GDR was contraindicated and the rationale. On 06/14/23 at 09:13 AM, observation reveal R17 in her room, sitting in her recliner, with eyes closed, walker next to recliner, bed in low position, call light within reach. On 06/19/23 at 10:20 AM, Administrative Nurse D reported the pharmacy review had been sent to the physician on 04/05/23 and verified the physician had not responded to the recommendation. The facility's Psychotropic Medication policy, dated 06/02/16, documented physician and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. The facility will make every effort to comply with state and federal regulation related to the use of psychopharmacological medication in the long-term care facility to include regular review of continued need, appropriate dosage, side effects, risk and/or benefits. The pharmacist and/or consulting pharmacist with monitor psychotropic drug use in the facility to ensure medications are not used in excessive doses or for excessive duration. Conduct a monthly medication review of residents and report findings to interdisciplinary team. Notifies the physician and nursing whenever medication is past due review and make recommendations for gradual dose reductions as indicated. The facility failed to attempt a GDR or document a physician response for contraindication which placed R17 at risk for adverse side effects related to psychotropic medication use. - The Electronic Medical Record (EMR) documented R19 had diagnoses of late onset Alzheimer dementia without behavioral disturbance (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had long and short-term memory problems and was independent with all activities of daily living (ADLs). R19 had disorganized thinking, hallucinations (perception of something not present), delusions (unshakable belief in something that's untrue), wandered one to three days, and had rejection of care four to six days. The MDS further documented R19 received antidepressant and antianxiety medication. The Care Plan, dated 05/31/23, documented Xanax had the following Black Box Warning (BBW-indicates that the drug carries a significant risk of serious or even life-threatening adverse effects) the resident at risk of abuse, addiction, respiratory depression and sedation. The Physician's Order, dated 05/30/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice per day, as needed, for the diagnosis of anxiety. The order lacked a stop date for the as needed medication. The Medication Administration Record (MAR) for June 2023 documented R19 received the as needed Xanax on 06/04, 06/05, 06/07, and 06/12/23 x 2. The Medication Regimen Review, dated 06/02/23 documented the physician must reorder as needed Xanax for a specific number of days via stop date or discontinue. The EMR lacked documentation the physician provided a stop date for the medication. On 06/14/23 at 08:00 AM, observation revealed R19 eating breakfast in the dining room conversing with her tablemate's. On 06/19/23 at 10:34 AM, Administrative Nurse D verified there was not a stop date for the as needed Xanax. The facility's Psychotropic Medication policy, dated 01/20, documented orders for as needed psychotropic medications would be time limited (ie: two weeks) and only for specific clearly documented circumstances. The facility failed to ensure R19's as needed Xanax had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic medication.

The facility had a census of 21 residents. The sample included 12 residents. Based on observations, record reviews, and interviews, the facility failed to ensure staff performed appropriate hand hygiene and/or glove usage during peri-care (involves washing the genital and rectal areas of the body or perineal area) for Resident (R) 8. This deficient practice had the risk for cross-contamination and increased risk for infection for the resident. Findings included: - On 12/16/21 at 10:40 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N entered R8's room, explained the procedure to the resident, applied gloves, and pulled down the residents' pants. CNA M unfastened the incontinent brief from the front of the resident, tucked it between the resident's legs. Wearing the same gloves, she removed an incontinent wipe package from the bedside table drawer and took out some wipes. CNA M placed the wipes and container on the resident's bed, provided peri-care to the resident's genitals and groin area. CNA N repositioned R8 to his left side while CNA M pulled the incontinent brief through the resident's legs to his backside, which revealed a small amount of soft formed brown bowel movement. CNA M provided perineal care to the resident's buttocks and rectal area and discarded the soiled incontinent brief in the trash. CNA M, with the same soiled gloves, placed the incontinent wipe package into the bedside table drawer, retrieved a container of powder, placed a new incontinent brief underneath the resident, sprinkled the powder on the resident's genitals, touched R8's shirt and pant leg, placed the powder and the incontinent wipes back in the drawer. CNA M then removed and discarded her soiled gloves. On 12/16/21 at 10:45 AM, CNA M verified she had not changed gloves after providing perineal care in the observation above. CNa M stated she should have changed her gloves and performed hand hygiene between glove changes. On 12/21/21 at 10:43 AM Administrative Nurse D stated she expected staff to change gloves between dirty and clean when providing incontinent cares. The facility's Standard Precautions policy, revised July 2018 , documented gloves should be changed between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms (a living thing that is too small to be seen with the naked eye, examples of microorganisms include bacteria). The facility staff failed to change gloves after providing perineal care, placing R8 at risk for development of infection and contamination.