**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 35 residents, the sample included 12 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 29 and/or his representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These practices had the potential to lead to uninformed decisions regarding treatment.Findings included:- Review of the Electronic Health Record (EHR) for R29 included diagnoses of unspecified psychosis not due to a substance or known physiological condition (when a person experiences psychotic symptoms but the specific cause isn't clear, and it's not linked to substance use or a known medical condition), neuroleptic induced parkinsonism (a form of drug-induced parkinsonism that occurs as a side effect of certain medications, particularly those used to treat psychiatric disorders like schizophrenia), extrapyramidal and movement disorder (movement disorders as a result of taking certain medications), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R29's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The MDS indicated that R29 used a wheelchair for mobility and was dependent on staff for all care and activities of daily living (ADLs).The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 01/06/25, documented R29 was dependent on staff for care and ADLs.The Psychotropic Drug Use CAA, dated 01/06/25, documented R29 had been administered antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antianxiety (a class of medications that calm and relax people) medications.R29's Quarterly MDS, dated 07/02/25, documented a BIMS score of 14, which indicated cognitively intact. The MDS indicated that R29 used a wheelchair for mobility, required supervision or touching assistance for eating, and was dependent on staff for all other care and ADLs. The MDS further indicated that R29 used antipsychotic and antianxiety medications.R29's Care Plan, dated 12/27/22, documented R29 had impaired cognitive function/dementia or impaired thought processes related to dementia. An intervention dated 12/27/24 included the administration of ordered medications with orders and for staff to communicate with R29's family regarding his capabilities and needs.R29's Care Plan, dated 10/07/24, documented R29 used antipsychotic medications related to schizophrenia, schizoaffective disorder, and dementia with an additional diagnosis of extrapyramidal movement disorder. Interventions included the administering of medications as ordered; staff were to monitor and document for side effects and effectiveness, and staff were to discuss with the medical doctor and family related to the ongoing need for use of medication.R29's EHR revealed a psychotropic consent signed and dated 02/12/25 that listed clonazepam (an antianxiety medication) 0.5 mg to be given in the morning and one mg to be given at bedtime.R29's EHR documented a new order, dated 08/06/25, for clonazepam at one milligram (mg) three times daily.R29's EHR lacked evidence R29, or his representative, received education and/or informed consent regarding the clonazepam dosage and frequency increase. During an interview on 08/19/25 at 12:00 PM, Administrative Nurse D stated that the informed consent did not have to be updated if the medication that is listed on the consent was only a dosage change.During an interview on 08/19/25 at 12:05 PM, Administrative Nurse E stated that the most current psychotropic consent for R29 was from February of this year.During an interview on 08/20/25 at 12:20 PM, Administrative Staff A stated that informed consents did not have to be documented in writing and could be done verbally. The facility policy Psychotropic Medications, dated 06/2024, documented psychotropic medications included, but were not limited to, anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. The policy further documented that psychotropic medications were given based on a comprehensive resident assessment, and the facility ensured that residents who received these medications were not given them unless the drugs were necessary to treat a specific condition as diagnosed and documented in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 35 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 38 and/or their representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital and failed to provide a written notification to the resident and/or his representative for the reason of the resident's transfer to the hospital in a language easy to understand. This placed the resident at risk of not understanding bed hold policy or the reason of the transfer. Findings included:- R38's Electronic Medical Record (EMR) revealed a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R38's EMR documented a Progress Note which noted R38 transferred to the hospital on [DATE].R38's EMR lacked documentation of a bed hold and lacked documentation of written notification to the resident and/or his representative, which explained the reason for the transfer to the hospital.On 08/20/25 at 12:07 PM, Administrative Nurse D stated it was the expectation of the staff to have a bed hold signed when a resident transferred to the hospital. Administrative Nurse D confirmed that staff had not notified the resident and/or his representative in writing of the reason for transfer to the hospital.The facility policy for Discharge/Transfer, revised 02/22/23, included: Before the facility transfers or discharges a resident, the facility shall notify the resident and the resident's representative of the transfer or discharge in writing and in a language and manner they understand. The policy also included: Before transferring a resident to a hospital, the facility shall provide written information to the resident or resident representative, which specifies the duration of the state bed-hold policy.

The facility identified a census of 35 residents. The sample included 12 residents with three residents 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 observations, interviews, and record review, the facility failed to provide weekly wound assessments for Resident (R) 1. This deficient practice placed the resident at risk for developing pressure injuries and delayed wound healing. Findings included:- R1's Electronic Health Record (EHR) revealed a diagnosis of Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer of the left heel, chronic osteomyelitis (bone infection) of the left foot and ankle, Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) of the right foot, and Stage 2 pressure ulcer of the buttock dated 07/27/25. R1's 06/25/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. The MDS documented R1 had two Stage 1 (pressure wounds which appears reddened, does not blanche, and may be painful but is not open) pressure ulcers, two Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcers, and one Stage 4 pressure area.R1's 06/25/25 Pressure Ulcer Care Area Assessment (CAA) documented R1 had the potential for, and actual impairment to, skin integrity related to fragile skin and use of oxygen, and an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). R1 was admitted with a Stage 4 pressure ulcer to his left heel. R1's Care Plan documented R1 was admitted with a Stage 4 pressure ulcer to his left heel. A wound culture was completed during hospitalization and was positive for Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), and was treated for osteomyelitis until 06/22/25. R1's Care Plan documented R1's MDS coded a Stage 1 pressure ulcer on his right buttock, acquired in-house 06/16/25. R1 had a Stage 1 pressure ulcer on his left buttock, acquired in-house 06/16/25; a Stage 4 pressure ulcer on his left heel; a Stage 4 pressure ulcer on his right heel, and a Stage 3 pressure ulcer on his sacral (area over the tailbone) region that were present when he arrived back at the facility. R1's Care Plan documented that staff were to provide wound care as ordered. Staff were to graph the wounds on Thursday and send them to the doctor, initiated on 03/18/25. R1's Care Plan documented R1 was to have a cushion in his wheelchair to assist with offloading pressure points while seated in his wheelchair, initiated on 03/10/25. The plan directed staff to inform family and caregivers of any new area of skin breakdown, initiated on 03/10/25. The plan directed staff to monitor, document, and report to the doctor any changes in skin status: appearance, color, wound healing, signs or symptoms of infection, wound size and stage, initiated on 03/10/25. R1's Care Plan documented staff were to turn and reposition R1 as needed to prevent pressure areas and for comfort; initiated on 03/10/25.R1's Braden Scale for Pressure Score Risk dated 06/03/25 documented R1 had a pressure risk score of 17, which indicated a low risk for pressure areas. R1's Physician Order noted an order to measure the wound on R1's buttocks on a graph every Thursday and send it to the provider; ordered on 07/11/25.R1's Physician Order noted an order to clean wound on R1's buttocks and apply Allevyn (a foam dressing primarily used for managing wounds with moderate to high levels of exudate (fluid) and supporting a moist wound healing environment every day and as needed; ordered on 07/11/25. This order was discontinued on 07/28/25. R1's Wound Graph for the left buttock documented the wound was 2 centimeters (cm) x 1.1 cm on 07/24/25. It documented the treatment was Allevyn dressing every day and as needed. R1's Wound Graph for the left buttock documented the wound was 2 cm x 1.1 cm on 07/31/25. It documented the treatment was Allevyn dressing every day and as needed. No further wound graphs for the left buttock pressure ulcer were documented in R1's EHR. R1's Skin Condition Report dated 07/24/25 thru 08/14/25 documented R1 had a buttock wound that was cleansed, dressed per order, and graphed. R1's EHR lacked evidence of an active treatment or dressing for the buttocks after 07/28/25 and lacked documentation it was graphed or that the physician was aware after 08/05/25. On 08/19/25 at 9:01 AM, R1 laid in bed on his back with the head of the bed slightly elevated. On 08/19/25 at 12:05 PM, Certified Nurse Aide (CNA) N and CNA O, entered the room to transfer the resident. CNA O exposed R1's buttocks. It was dark pink/purple and was non-blanchable (visible skin redness that persists with the application of pressure). The right buttock had a dressing that was saturated with blood. There was another dressing over the coccyx (area over the tailbone). On 08/19/25 at 01:18 PM, Administrative Nurse E donned gloves and a gown. She exposed R1's buttocks and noted both buttocks and the coccyx had a deep pink/purple color and were non-blanchable when pressure was applied. There was 2.5cm x 2.9cm eschar (dead tissue) present. On 08/19/25 at 01:18 PM, Administrative Nurse E stated the wound should have had an order in the computer for a treatment. She also stated that the facility staff should have been graphing the wound and documenting it. She said she was previously unaware that R1 had wounds present to buttocks and coccyx.On 08/19/25 at 02:33 PM, Administrative Nurse D stated he expected there to be an order put in on onset of any wound and expected staff to perform ongoing monitoring and treatment. The facility's Wound Care and Pressure Ulcer policy dated 01/2023 documented all pressure ulcers shall be documented with location, stage, size, wound bed tissue, drainage, odor, treatment, and tolerance of the treatment.

The facility reported a census of 35 residents. The sample included 12 residents, which included one resident reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide necessary supervision and assistance required for safe ambulation for Resident (R) 6. This placed R6 at risk for falls and fall-related injuries. Findings included:- Review of the Electronic Health Record (EHR) revealed that R6 included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), other symptoms and signs involving cognitive functions and awareness (difficulties with memory, concentration, decision-making, problem-solving, and understanding, as well as changes in behavior and communication), a need for assistance with personal care (assistance with activities of daily living [ADLs] that an individual is unable to perform independently due to illness, disability, or advanced age), and repeated falls (two or more falls within a specific time frame, typically a year or six months).The 07/23/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of two, which indicated severe cognitive impairment. R6 required supervision or touching assistance with dressing, eating, and personal hygiene. R6 was dependent on staff for bathing ADLs.The 07/23/25 Cognitive Loss/Dementia Care Area Assessment (CAA), documented R6 had a BIMS score less than 13 and had occurrences of wandering.The 07/23/25 Urinary Incontinence and Indwelling Catheter CAA, documented R6 was frequently incontinent.The 07/23/25 Falls CAA documented R6 wandered daily and had frequent falls prior to admission.The 07/23/25 Psychotropic Drug Use CAA, documented R6 was administered an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication.R6's Care Plan dated 07/19/25 documented R6 was at high risk for wandering related to an alteration in neurological status from dementia and normal pressure hydrocephalus (NPH-fluid buildup in the brain), and R6 wore a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) bracelet on her wrist. Interventions directed staff to perform quarterly and as-needed elopement risk assessments to check the WanderGuard bracelet for placement and battery function daily.R6's Care Plan dated 07/22/25 documented R6 was a high fall risk, having scored 28 points on assessment completed on 07/17/25 due to new admission, history of falls, on high-risk medications, impaired cognition, incontinence, wandering, and impaired gait. Interventions instructed staff to follow the facility fall protocol; Physical Therapy (PT) was to evaluate and treat R6 as ordered or as needed.R6's EHR recorded an active Physician's Order dated 07/17/25 that documented R6 was to ambulate with assistance only.R6's EHR recorded an active Physician's Order dated 07/17/25, for PT and Occupational Therapy (OT) to assess and evaluate R6 due to her being considered high risk for falls on her admit fall assessment.R6's EHR recorded an active Physician's Order dated 07/17/25 that documented R6 was to ambulate with assistance only.During the survey, on 08/19/25 at 11:58 AM, R6 received a signed order that changed her ambulation from assistance only to supervision.Observed on 08/18/25 at 10:48 AM, R6 ambulated in the hall without assistance. Multiple staff walked by her without assisting her.Observed on 08/18/25 at 11:13 AM, R6 wandered the hall without assistance.Observed on 08/18/2025 at 03:31 PM, R6 stood up from a recliner in the resident common area and ambulated without assistance; multiple staff were present and did not assist her.During an interview on 08/18/25 at 10:55 AM, Certified Medication Aide (CMA) S reported that R6 does not have a walker; she was admitted with one, but she kept carrying it, so it was stopped. CMA S further reported that R6 did not have any ambulation orders and that she was allowed to ambulate freely.During an interview on 08/18/25 at 02:43 PM, Licensed Nurse (LN) G stated that R6 could ambulate alone without assistance. LN G then verified that R6 did have an order for ambulation with assistance only.During an interview on 08/18/25 at 02:47 PM, Administrative Nurse D verified that R6 had an order for ambulation with assistance only. Administrative Nurse D stated she expected staff to follow provider orders and the resident care plan.During an interview on 08/20/25 at 12:20 PM, Administrative Staff A stated that facility expectations included staff were to follow and fulfill the provider orders.The facility policy Incidents, Accidents, Falls, and Prevention, dated 01/2023, documented that it was the policy of the facility that residents would achieve the highest quality of life by providing supervision and interventions that were deemed necessary to minimize significant injuries.

The facility reported a census of 35 residents. The sample included 12 residents. Based on interviews, record reviews and observation, the facility staff failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)1 who had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). The facility failed to follow adequate hand hygiene and infection control practices related to catheter bags and tubing as well as sanitary storage of nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs). This deficient practice placed the residents at increased risk for infections. Findings included:- Observed on 08/18/25 at 08:35, R22 was in his recliner in his room with his nebulizer on his overbed table. The nebulizer had fluid in it, and the face mask had a greasy film on it. R22 stated staff did not rinse out his nebulizer after each use and said he did not do it either.Observed on 08/18/25 at 09:19 AM, R4's Foley urine collection bag with dignity cover laid on the floor under his wheelchair.Observed on 08/19/25 at 08:00 AM, R4 was in the dining room in his wheelchair. R4's urinary catheter urine collection bag and dignity cover rested on the floor under his wheelchair.Observed on 08/19/25 at 08:16 AM, R4 wheeled himself out of the dining room in his wheelchair and his urinary catheter and collection bag with dignity bag, dragging the floor under his wheelchair.Observed on 08/19/25 at 08:39 AM, R4 wheeled himself about the common area in his wheelchair; his urinary collection bag with a dignity cover was dragging on the floor.Observed on 08/19/25 at 10:39 AM, R1 laid in bed with the catheter bag on the floor. The Foley bag was not covered with a dignity bag. Observed on 08/19/25 at 12:05 PM, Certified Nurse Aide (CNA) N and CNA O entered R1's room. CNA N donned gloves, but no gown. CNA O did not have gloves or a gown on. CNA O pulled R1's pants and incontinence brief down to expose R1's buttock dressings. The CNAs rolled R1 to place the sling under him, then attached the lift sling to the lift. CNA N lifted R1, and CNA O removed the catheter bag and held it with her ungloved hands. CNA O transferred the catheter bag and hung it on the sling. CNA N removed R1's boots, and they lowered R1 into the wheelchair. CNA O handed the catheter bag to CNA N. CNA N placed the bag on the floor. CNA O retrieved the urinal from the bathroom, and CNA N emptied the catheter. CNA N attached the dignity bag to the wheelchair, then picked up the catheter bag off the floor and placed it in the dignity bag.Observed on 08/19/25 at 03:00 PM, R4 sat in his wheelchair in his room, his urinary collection bag with a dignity cover was resting on the floor.Observed on 08/20/25 at 08:27 AM, R4 sat in his wheelchair in the resident common area; his urinary dignity bag and tubing were resting on the floor under his wheelchair.Observed on 08/20/25 at 10:17 AM, CNA M and a hospice CNA donned gowns and gloves and entered R1's room. The CNAs transferred R1 into the bed. Licensed Nurse (LN) I entered the room. The CNAs rolled R1 to the side to expose the wounds. LN 1 attained the trash can and placed it by her. CNA M exposed R1's buttocks. LN I removed the dressing and cleaned the buttock with wound cleanser. The buttock was deep red with a purple tint. LN I applied a clean dressing without performing hand hygiene and changing gloves. LN I then applied Calmoseptine (skin protectant and moisture barrier) with the same soiled gloves. LN I removed the gown and gloves and left the room.During an interview on 08/19/25 at 08:35 AM, CNA M stated that urinary catheter bags were supposed to have been positioned below the resident's bladder and should not have rested or dragged on the floor. CNA M verified that R4's urinary dignity bag had been resting and dragging on the floor.On 08/19/25 at 12:22 PM, CNA O stated that R1 was on EBP and staff should wear the proper personal protective equipment (PPE), which included gloves and a gown when providing care for a resident with a catheter. CNA O said staff should also do hand hygiene before entering the room and after removing the PPE, and between dirty and clean areas.On 08/19/25 at 11:30 AM, LN H stated the catheter bag should not lie on the floor and stated it should be in a dignity bag.On 08/20/25 at 10:17 AM LN I stated she should have completed hand hygiene and changed gloves after removing the dirty dressing, before touching the clean dressing.During an interview on 08/19/25 at 09:37 AM, Administrative Nurse E stated that if a resident had a urinary catheter, open wound, or infection of some type, there should have been EBP PPE established. On 08/20/25 at 12:21 PM, Administrative Nurse D stated it was his expectation for all staff to use good infection control practices. He said the nebulizers should be rinsed out after each use and placed to dry, then placed in a bag. Administrative Nurse D stated all staff should wash hands or use hand sanitizer when needed; during wound dressing change, staff should change gloves and wash hands after removing the dressing, before applying a clean dressing. He said catheter bags should always be placed in a dignity bag; they should never be on the floor, and EBP should be followed.The facility's Wound Care and Pressure Ulcer policy dated 01/2023 documented during a wound treatment remove and dispose of gloves after removing the old dressing. Apply clean gloves to apply the new dressing.The Infection Prevention Manual for Long Term Care Urinary catheter section documented catheters were to be off the floor and hand hygiene was to be performed before and after touching the bag.The facility's policy Enhanced Barrier Precautions documented that a gown and gloves were to be used during transfers and catheter care.

The facility reported a census of 35 residents. The sample included 12 residents. Based on interviews, record review, and observation, the facility failed to ensure residents had safe and properly maintained resident care equipment. This deficient practice placed the residents at risk for infection and decreased comfort.Findings included:- Observed on 08/18/25 at 11:08 AM, the leg pad on one sit-to-stand lift (medical devices designed to assist individuals with limited mobility in transitioning from a seated to a standing position) had a large, missing chunk from the leg pad, the foam resident grips were missing pieces, and there was exposed rust on the legs. Observed on 08/19/25 at 03:15 PM, the second sit-to-stand had multiple large areas of the foot base with exposed rust, the right resident hand-hold had approximately half the foam missing, exposing metal, and the left hand-hold foam was ripped, exposing metal. During an interview on 08/18/25 at 11:08 AM, Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) M stated that the sit-to-stand (one) damage had been reported to administration at least a month ago.During an interview on 08/19/25 at 03:15 PM, CNA M stated that damage to sit-to-stand two had not been reported.During an interview on 08/19/25 at 03:20 PM, Administrative Nurse D stated that the expectation was for staff to report any equipment concerns to maintenance so that the equipment parts could be ordered, repaired, or replaced as needed.During an interview on 08/19/25 at 03:36 PM, Administrative Staff A stated that maintenance was to be notified of any necessary repairs of equipment so that parts or replacements could be ordered, and the focus with the lifts had been on the resident lings.During an interview on 08/20/25 at 08:45 AM, Maintenance U reported that he did a monthly check of equipment, and if the equipment was damaged or broken, then he began the procedure to repair or replace the equipment. Maintenance U stated that he was unaware of the full damage to sit-to-stand one and was totally unaware of any damage to sit-to-stand two. The facility policy Leisure Homestead Association Policies and Procedures Patient Lifts, dated 09/24/23, documented that malfunctions or needed repairs were to be reported and that lifts were to be inspected monthly by maintenance.

The facility reported a census of 35 residents, one kitchen and one kitchenette. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for foodborne bacteria. This placed the residents at risk of food-borne illnesses.Findings included:- During an initial tour of the kitchen on 08/18/25 at 11:03 AM, the following areas of concern were noted: The reach-in refrigerator/freezer unit had seven of eight wired shelves with large areas of missing protective and plastic coating, making them unsanitizable.The two-door reach-in freezer had eight wired shelves with large areas of missing protective and plastic coating, making them unsanitizable.The dry storage rack by the back door had a heavy build-up of dirt on the bottom rim of the shelving unit.One red and three white plastic cutting boards were heavily gouged.The area next to the steam table had two shelves which held items such as assorted syrups and breakfast items had littered food debris.Three plastic containers used to store dry cereal had a build-up of dust on the lids. On 08/20/25 at 11:13 AM, Dietary Staff BB confirmed the areas noted needed to be cleaned. The facility policy for Reach-In Refrigerators and Freezers, undated, included: Staff shall thoroughly clean, rinse and sanitize the inside and outside of the reach-in refrigerator and freezer doors, racks, and bottom shelf monthly with a clean cloth dipped in warm detergent solution.The facility policy for Reach-In Refrigerators and Freezers, undated, included: Staff shall wash the insides of cupboards and drawers with a warm detergent solution, rinse and sanitize weekly.

The facility reported a census of 33 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set MDS for one sampled resident, Resident (R)7, with a CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with obstructive sleep apnea [OSA - a condition in which a person cannot maintain an open airway while sleeping]). This placed the resident at risk for uncommunicated care needs. Findings include: - R7's pertinent diagnoses from the Electronic Health Record (EHR) documented OSA (a condition in which a person cannot maintain an open airway while sleeping). The 10/12/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required limited assistance of one staff for dressing and personal hygiene, otherwise was independent with cares. Documented that R7 was not receiving non-invasive mechanical ventilation (CPAP). The 10/12/22 Care Area Assessment (CAA) lacked documentation related to CPAP use. The 07/11/23 Quarterly MDS documented a BIMS 15, indicating intact cognition. The resident required extensive assistance of one to two staff all cares. The 09/19/23 Care Plan documented R7 utilized a CPAP at night and instructed staff to clean the CPAP machine every day, but lacked instructions for storage of CPAP machine or associated equipment. R7's EHR Physician Orders included on 04/27/22 CPAP use every night with instructions to wash face and apply mask, then fill water chamber with distilled water. Additional orders for every morning for staff to remove mask from headgear and tubing and clean with warm soapy water and allow to air dry. Additionally, orders documented for staff to clean tubing with warm soapy water and to flush inside of tubing with warm soapy water, then reconnect tubing to machine and turn machine on to air dry inside of tubing. On 09/18/23 at 01:01 PM, R7 observed resting in recliner with a CPAP mask draped across the bed post and the nasal mask in direct contact with the bed post. In addition, there were two unlabeled jugs containing an unknown clear liquid stored upright on the floor between the bed and the bedside table. On 09/19/23 at 11:10 AM, R7's room observed to have a CPAP mask draped across the bed post and the nasal mask in direct contact with the bed post. There was one unlabeled jug containing an unknown clear liquid stored directly on the floor between the bed and the bedside table, and one unlabeled jug containing an unknown clear liquid laying sideways on the floor between the bed and the bedside table. On 09/20/23 at 08:11 AM, R7's room observed to have a CPAP mask draped across the bed post with the nasal mask in direct contact on the resident's bed post, and one unlabeled jug containing an unknown clear liquid sitting upright on the floor between the bed and the bedside table and one unlabeled jug containing an unknown clear liquid laying sideways on the floor between the bed and the bedside table. On 09/20/23 at 03:59 PM, Administrative Nurse C stated that MDS assessments are performed off-site by a third-party contractor. On 09/19/23 at 02:30 PM, Administrative Nurse B and Administrative Nurse C stated the facility used the Resident Assessment Instrument (RAI) manual for guidance in completing the MDS, CAA, and care planning. The facility failed to accurately complete the MDS for R7, regarding the use the CPAP machine. This placed the resident at risk for uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 33 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to apply TED hose (thrombo-embolic-deterrent - specialized compression stockings designed to help manage swelling of the feet/legs) every morning and remove them every night for Resident (R) 21. This deficient practice had the potential to place R21 at an increased risk for development of additional medical problems. Findings included: - R21's Electronic Medical Record (EMR) included a diagnosis of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) affecting right side, localized edema (swelling resulting from excessive accumulation of fluid in the body tissues), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and venous insufficiency. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. No behaviors documented with rejections of cares. R21 received a diuretic (a class of medications used promote the formation and excretion of urine) medication daily during the seven-day look-back period. The Quarterly MDS dated 06/19/23 documented a BIMS of 12, indicating moderately impaired cognition. No behaviors documented with rejection of cares. R21 received a diuretic medication daily during the seven-day look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/19/22 lacked documentation about behaviors related to rejection of cares. The ADL Functional/Rehabilitation Potential CAA, dated 12/19/22, lacked documentation about behaviors related to rejection of cares. The Care Plan dated 09/19/23, documented an entry on 12/13/22 that R21 was at risk for alteration in skin integrity related to right hemiplegia and localized edema, however, the care plan lacked guidance related to compression stockings to the resident's legs. The Physician's orders on 09/10/23 documented for staff to apply TED hose (thrombo-embolic-deterrent - specialized compression stockings designed to help manage swelling of the feet and legs) every morning and remove at bedtime. The Progress Notes reviewed from 08/01/23 to 09/17/23 and revealed the following concerns: 1. On 08/15/23 an entry that documented an order for compression stockings was sent to pharmacy. 2. On 08/16/23 an entry that documented TED hose not applied with the reason given that a bigger size had been ordered. 3. On 08/17/23 an entry that documented TED hose not applied with the reason given that a bigger size had been ordered. 4. On 09/16/23 an entry that documented TED hose not applied with the reason given is that resident stated that they have not been received yet (from the pharmacy). 5. On 09/17/23 an entry that documented TED hose not applied with the reason given is that the facility was awaiting delivery (of TED hose from the pharmacy). On 09/18/23 at 03:36 PM, R21 observed sitting in her electric wheelchair with swelling to both lower legs and lacked the physician ordered TED hose on her lower legs. On 09/19/23 at 01:48 PM, R21 observed sitting in her electric wheelchair and lacked TED hose on her lower legs. On 09/20/23 at 08:06 AM, R21 observed sitting in her electric wheelchair and lacked TED hose on her lower legs. On 09/20/23 at 02:11 PM, R21 remained to not be wearing her TED hose to her lower legs. On 09/21/23 at 07:58 AM, R21 remained without TED hose to her lower legs. On 09/18/23 at 03:26 PM, R21 revealed that she was to be wearing TED hose, but the staff doesn't have them for her. On 09/21/23 at 08:50 AM, Licensed (LN) F revealed that the Certified Nurse Aide (CNA) staff were responsible for application of TED hose each morning and removal of TED hose each evening. In the absence of TED hose, elastic bandages such as ACE wraps should be utilized to provide compression to resident's legs. On 09/21/23 at 11:25 AM, CNA G revealed that the resident wore TED hose without complaint but refused to wear them on shower days, which are twice per week, because the CNA staff attempt to place hose on resident before she's completely dried off and R21 does not like this. CNA G denied using a different product such as ACE wraps to provide compression to resident's legs. On 09/21/23 at 11:32 AM, CNA H revealed that resident is not currently wearing TED hose because the only ones that are in the facility were too small, and a larger size has been ordered by Administrative Staff L. CNA H denied using a different product such as ACE wraps to provide compression to the resident's legs and stated that she didn't know if any such products were available in the facility. On 09/20/23 at 02:59 PM, Administrative Nurse C revealed that the CNA staff are responsible for morning cares which included putting TED hose on residents, but ultimately the nurse that's on duty was responsible to ensure the tasks were completed. The expectation is for staff to follow physician orders as they are written. The facility's Physician Orders policy, dated 01/2022, lacked instructions for staff to follow and/or carry out physician's orders as written. The facility's Care Plans policy, dated 01/2023 documented that the facility would develop and implement a comprehensive person-centered care plan for each residence in accordance with the RAI (resident assessment instrument), consistent with the resident rights and includes measurable objectives to meet the resident's needs. The policy lacked documentation related to care plan revision to comply with on-going resident's needs. The facility failed to apply TED hose every morning and remove them every night for R21. This deficient practice had the potential to place R21 at an increased risk for development of additional medical problems.

The facility reported a census of 33 residents with 12 residents sampled, including four residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly clean and store the nebulizer (a device for administering inhaled medications) for Resident (R)9 and R31 in accordance with the standards of care. In addition, the facility failed to disassemble and clean the CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with obstructive sleep apnea [OSA - a condition in which a person cannot maintain an open airway while sleeping]) and to correctly store distilled water used for humidification in the CPAP for R7. Findings included: - R7's pertinent diagnoses from the Electronic Health Record (EHR) documented OSA (a condition in which a person cannot maintain an open airway while sleeping). The 10/12/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required limited assistance of one staff for dressing and personal hygiene, otherwise was independent with cares. The 10/12/22 Care Area Assessment (CAA) lacked documentation related to the CPAP use. The 07/11/23 Quarterly MDS documented a BIMS 15, indicating intact cognition. The resident required extensive assistance of one to two staff all cares. The 09/19/23 Care Plan documented that R7 utilized a CPAP at night and instructed staff to clean the CPAP machine every day but lacked instructions for storage of CPAP machine or associated equipment. R7's EHR Physician Orders included on 04/27/22 CPAP use every night with instructions to wash face and apply mask, then fill water chamber with distilled water. Additional orders for every morning for staff to remove mask from headgear and tubing and clean with warm soapy water and allow to air dry. Additionally, orders documented for staff to clean tubing with warm soapy water and to flush inside of tubing with warm soapy water, then reconnect tubing to machine and turn machine on to air dry inside of tubing. On 09/18/23 at 01:01 PM, R7 observed resting in recliner with a CPAP mask draped across the bed post and the nasal mask in direct contact with the bed post. In addition, there were two unlabeled jugs containing an unknown clear liquid stored upright on the floor between the bed and the bedside table. On 09/19/23 at 11:10 AM, R7's room observed to have a CPAP mask draped across the bed post and the nasal mask in direct contact with the bed post. There was one unlabeled jug containing an unknown clear liquid stored directly on the floor between the bed and the bedside table, and one unlabeled jug containing an unknown clear liquid laying sideways on the floor between the bed and the bedside table. On 09/20/23 at 08:11 AM, R7's room observed to have a CPAP mask draped across the bed post with the nasal mask in direct contact on the resident's bed post, and one unlabeled jug containing an unknown clear liquid sitting upright on the floor between the bed and the bedside table and one unlabeled jug containing an unknown clear liquid laying sideways on the floor between the bed and the bedside table. On 09/20/23 at 02:00 PM, Certified Nurse Aide (CNA) D revealed that CNAs would get R7 up for the morning and take off his CPAP mask but denied knowledge of care of the equipment. On 09/20/23 at 03:59 PM, Administrative Nurse C revealed that the CNAs were expected to clean the CPAP and tubing/mask every morning and the tubing and mask should be stored in a bag. Administrative Nurse C was unable to describe the cleaning procedure for the CPAP tubing/mask. Further stated that bottles of distilled water for the CPAP should be labeled with contents and open/expiration dates and stored off the floor for infection control concerns. On 09/21/23 at 08:50 AM, Licensed Nurse (LN) F revealed CNAs were responsible for AM cares including taking the resident's CPAP machine off as well as care of the equipment. The CPAP humidifiers were to be filled with distilled water. Staff should not store distilled water on the floor, but rather on a shelf somewhere inside the resident's room. LN F stated that the CPAP masks/tubing should be stored in a way that they can be kept sanitary and clean and not touching the headboard and/or footboard of the resident's bed. The tubing and mask should be cleaned every day with isopropyl alcohol swabs and not with soapy water. The facility's Maintenance and Cleaning of Nebulizers / CPAP policy, dated 04/2022, lacked instructions specific to CPAP machine care and maintenance. The facility failed to provide respiratory care consistent with professional standards of care for R7, regarding the use and cleaning of the CPAP machine. - R9's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic bronchitis (long term inflammation of the large airways in the lungs) and cough. The 10/12/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with all cares. The 10/12/22 Care Area Assessment (CAA) lacked documentation related to inhaled medication use. The 07/11/23 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition. The resident required supervision and setup for all cares. The 09/19/23 Care Plan documented an entry on 04/10/23 that R9 had altered respiratory status related to diagnosis of chronic bronchitis and instructed staff to administer breathing treatments as ordered and to monitor the resident for changes in respiratory status. R9's Physician Orders included Albuterol Sulfate (a medication used to open and relax airway structures), 2.5 milligrams (mg) in 0.5 milliter (mL) to be inhaled orally, via nebulizer, four times per day, for shortness of air and wheezing, related to chronic bronchitis, ordered 10/11/21. On 09/18/23 at 04:45 PM, R9 revealed staff bring the medicine to him and put it in the nebulizer, turn the machine on, then leave. At the completion of his treatment, he turns the machine off and sits the nebulizer on the over-the-bed table where it sits until the next treatment. On 09/18/23 at 04:45 PM, R9's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid observed in the nebulizer chamber. On 09/19/23 at 01:49 PM, R9's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid observed in the nebulizer chamber. On 09/20/23 at 08:07 AM, R9's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid observed in the nebulizer chamber. On 09/20/23 at 03:59 PM, Administrative Nurse C stated that the expectation for staff was that after breathing treatments completed, staff should rinse the nebulizer chamber with water. On 09/21/23 at 08:50 AM, Licensed Nurse (LN) F revealed that Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) do not do anything with the nebulizers as it is a nursing responsibility to administer treatments and care for the equipment. LN F stated that in between treatments, nebulizers should be rinsed out without being disassembled and set on the counter in the room in preparation for the next treatment. After the last treatment of the day, the nebulizers should be disassembled, rinsed out with water, and set on a paper towel to dry overnight. The facility's Maintenance and Cleaning of Nebulizers / CPAP policy, dated 04/2022, documented that after each treatment, nebulizers were to be disassembled and rinsed under a strong stream of water, shaken dry, placed on a paper towel and covered with another paper towel and allowed to air dry. Once dry, reassembled for the next treatment. Further documented that twice weekly, nebulizer was to be disassembled and soaked for 30 minutes in a liquid disinfectant (one-part white vinegar, one-part water), rinsed with water, and allowed to air dry between the folds of paper towels or a clean hand towel. When thoroughly dry, store in a plastic bag until ready for use. The facility failed to provide respiratory care consistent with professional standards of care for R9, regarding the use and cleaning of the nebulizer equipment. - R31's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 02/01/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The resident was independent with all cares. The 02/01/23 Care Area Assessment (CAA) lacked documentation related to inhaled medication use. The 07/13/23 Quarterly MDS documented a BIMS of 13, indicating intact cognition. The resident required supervision and setup for all cares. The 09/21/23 Care Plan documented an entry on 02/07/23 that R31 was at risk for respiratory distress related to disease process of COPD and instructed staff to administer medications as ordered and to monitor resident for effectiveness. R31's Physician Orders included Ipratropium-Albuterol Sulfate (a medication used to open and relax airway structures), 0.5-2.5 milligrams (mg) in 3 milliter (mL), to be inhaled orally via nebulizer, every six hours as needed for for shortness of air and wheezing related to COPD, ordered 05/22/23. On 09/18/23 at 02:26 PM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/19/23 at 01:50 PM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/20/23 at 10:00 AM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/20/23 at 03:59 PM, Administrative Nurse C stated that the expectation for staff was that after breathing treatments were completed, the nebulizer chamber should be rinsed with water. On 09/21/23 at 08:50 AM, Licensed Nurse (LN) F revealed that Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) do not do anything with the nebulizers as it is a nursing responsibility to administer treatments and care for the equipment. LN F stated that in between treatments, nebulizers should be rinsed out without being disassembled and set on the counter in the room in preparation for the next treatment. After the last treatment of the day, the nebulizers were to be disassembled, rinsed out with water, and set on a paper towel to dry overnight. The facility's Maintenance and Cleaning of Nebulizers / CPAP policy, dated 04/2022, documented that after each treatment, nebulizers were to be disassembled and rinsed under a strong stream of water, shaken dry, placed on a paper towel, covered with another paper towel, and allowed to air dry. Once dry, reassembled for the next treatment. Further documented that twice weekly, nebulizer was to be disassembled and soaked for 30 minutes in a liquid disinfectant (one-part white vinegar, one-part water), rinsed with water, and allowed to air dry between the folds of paper towels or a clean hand towel. When thoroughly dry, store in a plastic bag until ready for use. The facility failed to provide respiratory care consistent with professional standards of care for R31, regarding the use and cleaning of the nebulizer equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R32's the Electronic Medical Record (EMR) included a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion) and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait [manner or style of walking], muscle rigidity and weakness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had short term and long-term memory problems. The resident had severely impaired cognitive skills for daily decision making. Required limited assistance of one to two staff for all cares except eating and bed mobility which were independent. The resident had falls prior to admission to the facility. The Quarterly MDS dated 07/24/23 documented the resident had severely impaired cognition. R32 required extensive assistance of one to two staff for all cares. He had two or more non injury falls, and two or more injury falls since the previous assessment. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 02/22/23 documented a diagnosis of dementia. The Behavioral Symptoms CAA, dated 02/22/23 triggered on the assessment but lacked documentation or analysis of findings. The Falls CAA was not triggered on the assessment. The 09/20/23 Care Plan documented an entry on 02/22/23 that R32 was a high risk of falls related to confusion, gait/balance problems, diagnoses of Parkinson's and dementia. The care plan lacked appropriate person-centered revisions for the multiple falls the resident had that occurred on 03/02/23, 03/10/23, 03/15/23, 03/28/23, 04/06/23, 04/08/23, 05/19/23, 05/30/23, 07/05/23, and 07/15/23. Review of fall reports from 02/22/23 to 09/20/23 revealed the following concerns: 1. On 03/02/23 at 10:10 PM, R32 had a fall from standing height. The facility determined the root cause to be that the resident attempted to ambulate without assistance. The nurse on duty initiated the immediate interventions of 1:1 supervision, to walk with the resident and offer food/drink. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 2. On 03/10/23 at 03:00 PM, R32 had a fall from his wheelchair. The facility determined the root cause was the resident was attempted to stand and transfer without assistance. The nurse on duty initiated the immediate intervention of frequent monitoring and redirection efforts from staff. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 3. On 03/15/23 at 05:00 AM, R32 had an unwitnessed fall from unknown height. The facility determined the root cause was the resident was left unattended asleep in a recliner in the common while staff performed bed checks. The nurse on duty initiated the immediate intervention for resident to be supervised during bed checks. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 4. On 03/28/23 at 03:15 AM, R32 had an unwitnessed fall from unknown height. The investigation lacked a root cause analysis and immediate intervention by the staff on duty at the time of the fall. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 5. On 04/06/23 at 08:00 PM, R32 had a fall from his wheelchair. The root cause determined to be resident's confusion, unlocked wheelchair, and resident's attempt to ambulate without assistance. The nurse on duty initiated the immediate intervention of 1:1 supervision of the resident. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 6. On 04/08/23 at 04:30 PM, R32 had a fall from his wheelchair. The root cause determined to be resident's confusion. The nurse on duty initiated the immediate intervention of 1:1 supervision of the resident. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 7. On 05/19/23 at 04:50 AM, R32 had a fall from his wheelchair. The root cause determined to be the resident attempted to ambulate without assistance to void. The nurse on duty initiated the immediate intervention for resident's brief to be checked and changed every four hours. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 8. On 05/30/23 at 02:30 PM, R32 had a fall from his wheelchair. The root cause determined to be improper footwear. The nurse on duty initiated the immediate intervention for R32 to always wear appropriate footwear or gripper socks while not in bed. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 9. On 07/05/23 at 02:45 PM, R32 had an unwitnessed fall from his recliner. The root cause determined to be that R32 attempted to get to the bathroom unassisted by staff. The nurse on duty initiated the immediate duplicate intervention for staff to take the resident to the toilet at the start of each shift. The care plan lacked a new unique corresponding dated entry with interventions to mitigate the risk of future falls, as the intervention was already documented in place on the care plan after a non-injury fall on 03/05/23. 10. On 07/15/23 at 11:05 PM, R32 had an unwitnessed fall from a recliner in the common area. The root cause determined to be that the chair in which R32 was sitting had broken. The nurse on duty initiated an unrelated immediate intervention of diversionary activities. The care plan lacked an appropriate dated intervention to mitigate the risk of future falls that addressed the root cause. On 09/20/23 at 02:16 PM, Licensed Nurse (LN) J revealed that after a fall, the nurse on duty should complete the fall report and determine the root cause of the fall, develop an immediate intervention that goes on the fall report and implement that intervention into the care plan. The fall report with the interventions goes to Administrative Nurse B and Administrative Nurse C's office for them to review on the next business day, and they may change the intervention or develop a new intervention on the care plan. On 09/20/23 at 02:59 PM, Administrative Nurse C revealed that following a fall, the nurse on duty at the time of the fall was responsible for developing an immediate intervention and making an entry into the care plan to address the root cause of the fall. The fall report is then reviewed by Administrative Nurse C and discussed with Administrative Nurse B. Administrative Nurse C confirmed duplicate and missing care plan entries related to falls for R32. The facility's Care Plans policy, dated 01/2023 documented that the facility would develop and implement a comprehensive person-centered care plan for each resident in accordance with the RAI (resident assessment instrument), consistent with the resident rights and includes measurable objectives to meet the resident's needs. The policy lacked documentation related to care plan revision to comply with on-going resident's needs. The facility failed to review and revise R32's care plan related to the multiple falls on 03/02/23, 03/10/23, 03/15/23, 03/28/23, 04/06/23, 04/08/23, 05/19/23, 05/30/23, 07/05/23 and 07/15/23 lacked any new or relevant revisions to the resident's individualized care plan to prevent the resident from possible further falls. This deficient practice placed R32 at risk for injuries related to ongoing falls. - R21's Electronic Medical Record (EMR) included a diagnosis of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) affecting right side, localized edema (swelling resulting from excessive accumulation of fluid in the body tissues) and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and venous insufficiency. The admission Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) score of 9, indicating moderately impaired cognition. No behaviors documented with rejections of cares. R21 received a diuretic (a class of medications used promote the formation and excretion of urine) medication daily during the seven-day look-back period. The Quarterly MDS dated 06/19/23 documented a BIMS of 12, indicating moderately impaired cognition. No behaviors documented with rejection of cares. R21 received a diuretic medication daily during the seven-day look-back period. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 12/19/22 lacked documentation about behaviors related to rejection of cares. The ADL Functional / Rehabilitation Potential CAA, dated 12/19/22 lacked documentation about behaviors related to rejection of cares. The Care Plan dated 09/19/23 documented an entry on 12/13/22 where R21 was at risk for alteration in skin integrity related to right hemiplegia and localized edema, however, the care plan lacked guidance related to compression stockings to the resident's legs. The Physician's orders on 09/10/23 documented for staff to apply TED hose (thrombo-embolic-deterrent - specialized compression stockings designed to help manage swelling of the feet and legs) every morning and remove at bedtime. On 09/18/23 at 03:36 PM, R21 observed sitting in her electric wheelchair with swelling to both lower legs and lacked the physician ordered TED hose on her lower legs. On 09/19/23 at 01:48 PM, R21 observed sitting in her electric wheelchair and lacked TED hose on her lower legs. On 09/20/23 at 08:06 AM, R21 observed sitting in her electric wheelchair and lacked TED hose on her lower legs. On 09/20/23 at 02:11 PM, R21 remained to not be wearing her TED hose to her lower legs. On 09/21/23 at 07:58 AM, R21 remained without TED hose to her lower legs. On 09/18/23 at 03:26 PM, R21 revealed that she was to be wearing TED hose, but the staff doesn't have them for her. On 09/21/23 at 08:50 AM, Licensed (LN) F revealed that the Certified Nurse Aide (CNA) staff were responsible for application of TED hose each morning and removal of TED hose each evening. In the absence of TED hose, elastic bandages such as ACE wraps should be utilized to provide compression to resident's legs. On 09/21/23 at 11:25 AM, CNA G revealed that the resident wore TED hose without complaint but refused to wear them on shower days, which are twice per week, because the CNA staff attempt to place hose on resident before she's completely dried off and R21 does not like this. CNA G denied using a different product such as ACE wraps to provide compression to resident's legs. On 09/21/23 at 11:32 AM, CNA H revealed that resident is not currently wearing TED hose because the only ones that are in the facility were too small, and a larger size has been ordered by Administrative Staff L. CNA H denied using a different product such as ACE wraps to provide compression to the resident's legs and stated that she didn't know if any such products were available in the facility. On 09/20/23 at 02:59 PM, Administrative Nurse C revealed that the CNA staff are responsible for morning cares which included putting TED hose on residents, but ultimately the nurse that's on duty was responsible to ensure the tasks were completed. The expectation is for staff to follow physician orders as they are written. The facility's Physician Orders policy, dated 01/2022, lacked instructions for staff to follow and/or carry out physician's orders as written. The facility's Care Plans policy, dated 01/2023 documented that the facility would develop and implement a comprehensive person-centered care plan for each residence in accordance with the RAI (resident assessment instrument), consistent with the resident rights and includes measurable objectives to meet the resident's needs. The policy lacked documentation related to care plan revision to comply with on-going resident's needs. The facility failed to review and revise R21's care plan related to TED hose. This placed R21 at risk for not receiving necessary treatments as prescribed and placed R21 at increased risk for further development of additional medical problems. The facility reported a census of 33 residents with a sample of 12 residents. Based on observation, interview, and record review, the facility failed to review and revise the care plan with relevant interventions following falls to prevent further falls for four sampled residents (R)16, R10, R32, and failed to revise the care plan for R21, related to compression stockings. Findings included: - Resident (R)16's Physician Orders, dated 09/11/23, included diagnoses of muscle spasms, sprain of the left ankle, left hand pain, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), left and right shoulder pain, and obesity (severe overweight). The admission Minimum Data Set, (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status, (BIMS) score of 13, indicating cognitively intact. She required extensive assistance of staff for bed mobility, transfers, toilet use, and walking in the room. The resident used a walker and wheelchair as mobility devices. Her balance during transition was not steady but she was able to stabilize without staff assistance. She had no functional limitation in her range of motion of her upper or lower extremities. The Quarterly MDS, dated [DATE], documented changes which included a BIMS score of 12, indicating moderate cognitive impairment. The resident experienced one fall. The Care Plan, (CP) dated 08/12/23, directed staff the resident was at risk of falls related to muscle spasms, cataracts (clouding of the lens of the eye), rheumatoid arthritis, chronic pain, neuropathy (nerve damage or impairment), dependence on oxygen, morbid obesity, hypertension (elevated blood pressure), and deformity of the resident's left finger. The interventions included the following with their initiation date: 1. Educate the resident about safety reminders and what to do if a fall occurs. Date Initiated: 03/07/2022. 2. Dysom (skid resistant) in wheelchair. Date Initiated: 04/10/2023. 3. Check area before the resident starts to transfer to assure there is nothing on the floor that she could trip on. The resident's bed removed for more space in her room due to the resident sleeping in the recliner. Date initiated: 04/16/23. 4. Allow for rest breaks. Date Initiated: 05/16/2023. 5. Assure adequate lighting. Date Initiated: 05/16/2023. 6. Position the bed in low position when not giving care. Date Initiated 05/16/2023. 7. Consult the Physician for physical therapy (PT) or occupational therapy (OT) as needed (PRN). Date Initiated: 05/16/2023. 8. Ensure the call bell is within the resident's reach. Date Initiated 05/16/2023. 9. Ensure wheels are locked on the resident's wheelchair during transfers. Date Initiated 05/16/2023. Review of the Electronic Medical Record, (EMR), Progress Notes, dated 01/2023 through 06/2023, revealed the resident experienced falls on 01/24/23, 01/25/23, 04/08/23, 05/16/23, and 05/24/23. The CP lacked revision of appropriate new interventions following the falls on 01/24/23, 01/25/23, 04/08/22, and 05/24/23. The facility's Fall Investigation Follow-up, for the above falls documented the facility lacked a thorough investigation to determine the root cause and contributing factors of four of the five falls the resident experienced. Additionally, the facility failed to initiate an immediate appropriate intervention to prevent further falls for four of the above falls, on 01/24/23, 01/25/23, 04/08/23, and 05/24/23. On 09/18/23 at 01:13 PM, the resident was in a recliner with her legs elevated. The resident stated she had fallen multiple times and scraped herself up a couple of times. R16 reported last week she had to use the lift to get to the bedside commode. On 09/20/23 at 01:48 PM, Administrative Nurse C, stated staff should complete an assessment of a resident when they fall before the resident should be moved. The charge nurse should initiate the investigation and to determine the root cause of the fall and implement an immediate, appropriate, and new intervention to prevent further falls. She confirmed the above findings and agreed the fall investigations lacked a thorough investigation to determine root cause and staff failed to review and revise the care plan with appropriate, immediate, new interventions to prevent further falls. The facility policy, Falls and Fall Prevention, dated 01/16/22, documentation included interventions determined to be needed are to be put in place, as soon as possible to protect the resident, and should document the interventions on the care plan. The facility failed to review and revise the care plan with interventions following falls to prevent further falls for the dependent resident that experienced multiple falls. - Resident (R)10's Physician Orders, dated 08/21/23, documentation included diagnoses of hypertension (high blood pressure), poly-osteoarthritis (when at least five joints are affected with arthritis), osteoporosis (brittle and fragile bones), disorder of bone density and structure, insomnia (inability to sleep), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change in Status Minimum Data Set, (MDS) dated [DATE], documented the resident rarely/never understood. She required extensive assistance of staff for bed mobility and transfers. Walking did not occur. Her balance during transition was not steady. She required staff assistance to stabilize. The resident had no functional limitation in range of motion of upper or lower extremities and used a wheelchair as an assistive mobility device. The resident experienced two or more falls with no major injury. She was always incontinent of bowel and bladder. The Care Plan, (CP), dated 08/10/23, identified the resident was at risk for falls. Guidance to staff included the following: 1. Hi/Low bed with a fall mat on the floor, initiated 09/08/2020. 2. Ensure the resident is wearing appropriate footwear that provides a non-skid sole, initiated 09/08/2020. 3. Assure adequate lighting, initiated 05/09/23. (However, the progress notes revealed the resident fell out of her wheelchair while staff propelled her.) 4. Keep the resident's bed in a low position when not giving care, initiated 05/09/23. 5. Ensure the resident's call light is within reach, initiated 05/09/23. (However, the progress notes revealed the resident fell out of her wheelchair while staff propelled her.) Review of the resident's Progress Notes, dated 05/09/2023 at 07:13 PM, documentation included the staff propelled the resident in her wheelchair (w/c) into the living room. As they entered the living room, she leaned forward and fell out of her chair and onto the floor. It was noted that she had lost one of her shoes. The facility lacked a thorough fall Investigation, to determine the root cause and contributing factors of the fall on 05/09/23. The interventions placed at the time of the fall were unrelated to the fall that occurred, therefore did not address the actual causes of the fall. On 09/18/23 at 03:02 PM, Licensed Nurse (LN) F, stated the resident fell when staff was pushing her in the w/c, and she lunged forward. Staff had the resident sent to the hospital for evaluation. LN F reported the resident had pedals on her w/c, but the resident would remove her feet off the pedals. LN F stated when a resident falls, the charge nurse should assess the resident, initiate a falls investigation to determine the root cause of the fall and review and revise the care plan with a relevant, immediate intervention to mitigate the identified causes that contributed to the fall to prevent further falls. On 09/20/23 at 01:48 PM, Administrative Nurse C, stated staff should complete an assessment of a resident when they fall before the resident is moved. The charge nurse should initiate the investigation and to determine the root cause of the fall and implement an immediate, appropriate, and new intervention to prevent further falls. She confirmed the above findings and agreed the fall investigations lacked a thorough investigation to determine root cause and staff failed to review and revise the care plan with appropriate, immediate, new interventions to prevent further falls. The facility policy, Falls and Fall Prevention, dated 01/16/22, documentation included interventions determined to be needed are to be put in place, as soon as possible to protect the resident, and should document the interventions on the care plan. The facility failed to review and revise the care plan with interventions following falls to prevent further falls for the dependent resident that experienced multiple falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R32's the Electronic Medical Record (EMR) included a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion) and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait [manner or style of walking], muscle rigidity and weakness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had short term and long-term memory problems. The resident had severely impaired cognitive skills for daily decision making. The resident required limited assistance of one to two staff for all cares except eating and bed mobility which were independent. The resident had falls prior to admission to the facility. The Quarterly MDS dated 07/24/23 documented the resident had severely impaired cognition. R32 required extensive assistance of one to two staff for all cares. He had two or more non injury falls, and two or more injury falls since the previous assessment. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 02/22/23 documented a diagnosis of dementia. The Behavioral Symptoms CAA dated 02/22/23, triggered on the assessment but lacked documentation or analysis of findings. The Falls CAA was not triggered on the assessment. The 09/20/23 Care Plan documented an entry on 02/22/23 that R32 was a high risk of falls related to confusion, gait/balance problems, diagnoses of Parkinson's and dementia. Review of fall reports from 02/22/23 to 09/20/23 revealed the following concerns: 1. On 03/02/23 at 10:10 PM, R32 had a fall from standing height. The facility determined the root cause to be that the resident attempted to ambulate without assistance. The nurse on duty initiated the immediate interventions of 1:1 supervision, to walk with the resident and offer food/drink. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 2. On 03/10/23 at 03:00 PM, R32 had a fall from his wheelchair. The facility determined the root cause was the resident attempted to stand and transfer without assistance. The nurse on duty initiated the immediate intervention of frequent monitoring and redirection efforts from staff. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 3. On 03/15/23 at 05:00 AM, R32 had an unwitnessed fall from unknown height. The facility determined the root cause was the resident was left unattended asleep in a recliner in the common while staff performed bed checks. The nurse on duty initiated the immediate intervention for resident to be supervised during bed checks. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 4. On 03/28/23 at 03:15 AM, R32 had an unwitnessed fall from unknown height. The investigation lacked a root cause analysis and immediate intervention by the staff on duty at the time of the fall. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 5. On 04/06/23 at 08:00 PM, R32 had a fall from his wheelchair. The root cause determined to be resident's confusion, unlocked wheelchair, and resident's attempt to ambulate without assistance. The nurse on duty initiated the immediate intervention of 1:1 supervision of the resident. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 6. On 04/08/23 at 04:30 PM, R32 had a fall from his wheelchair. The root cause determined to be resident's confusion. The nurse on duty initiated the immediate intervention of 1:1 supervision of the resident. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 7. On 05/19/23 at 04:50 AM, R32 had a fall from his wheelchair. The root cause determined to be the resident attempted to ambulate without assistance to void. The nurse on duty initiated the immediate intervention for resident's brief to be checked and changed every four hours. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 8. On 05/30/23 at 02:30 PM, R32 had a fall from his wheelchair. The root cause determined to be improper footwear. The nurse on duty initiated the immediate intervention for R32 to always wear appropriate footwear or gripper socks while not in bed. The care plan lacked a corresponding dated entry with interventions to mitigate the risk of future falls. 9. On 07/05/23 at 02:45 PM, R32 had an unwitnessed fall from his recliner. The root cause determined to be that R32 attempted to get to the bathroom unassisted by staff. The nurse on duty initiated the immediate duplicate intervention for staff to take the resident to the toilet at the start of each shift. The care plan lacked a unique corresponding dated entry with interventions to mitigate the risk of future falls, as the intervention was already documented in place on the care plan after a non-injury fall on 03/05/23. 10. On 07/15/23 at 11:05 PM, R32 had an unwitnessed fall from a recliner in the common area. The root cause determined to be that the chair in which R32 was sitting had broken. The nurse on duty initiated an unrelated immediate intervention of diversionary activities. The care plan lacked an appropriate dated intervention to mitigate the risk of future falls that addressed the root cause. On 09/20/23 at 02:16 PM, Licensed Nurse (LN) J revealed that after a fall, the nurse on duty should complete the fall report and determine the root cause of the fall, develop an immediate intervention that goes on the fall report and implement that intervention into the care plan. The fall report with the interventions goes to Administrative Nurse B and Administrative Nurse C's office for them to review on the next business day, and they may change the intervention or develop a new intervention on the care plan. On 09/20/23 at 02:59 PM, Administrative Nurse C revealed that following a fall, the nurse on duty at the time of the fall was responsible for developing an immediate intervention and making an entry into the care plan to address the root cause of the fall. The fall report is then reviewed by Administrative Nurse C and discussed with Administrative Nurse B. Administrative Nurse C confirmed duplicate and missing care plan entries related to falls for R32. The facility policy, Falls and Fall Prevention, dated 01/16/22, documentation included interventions determined to be needed are to be put in place, as soon as possible to protect the resident, and should document the interventions on the care plan. The facility failed to thoroughly investigate the resident's falls to determine contributing factors or causes to implement new immediate relevant interventions to prevent further falls. This deficient practice placed R32 at risk for injuries related to ongoing falls. - Resident (R)7's pertinent diagnoses from the Electronic Health Record (EHR) documented restlessness and agitation and neuroleptic induced parkinsonism (a movement disorder caused as a side effect of certain medications that causes Parkinson's-like symptoms which includes [but not limited to] weakness, muscle rigidity, tremors, altered gait [manner or style of walking]). The 10/12/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required limited assistance of one staff for dressing and personal hygiene, otherwise was independent with cares. The 07/11/23 Quarterly MDS documented a BIMS 15, indicating intact cognition. The resident required extensive assistance of one to two staff for all cares. The 09/19/23 Care Plan documented an entry dated 12/19/22 that R7 had a history of actual falls related to an unsteady gait. On 09/20/23 at 01:58 PM, R7's room observed to have a wet floor and lacked a wet floor sign. On 09/20/23 at 02:00 PM, Housekeeping M confirmed that she had mopped R7's room and stated that she had failed to place a wet floor sign to alert the resident and staff that the floor was wet to prevent an accident and possible injury. The facility did not provide a policy related to placement of wet floor signs. The facility failed to place a wet floor sign to prevent a potential accident from occurring. This deficient practice placed R7 at risk for injuries related to falls. The facility reported a census of 33 residents with a sample of 12 residents which included four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to complete a thorough investigation to determine contributing factors and causes of falls to implement appropriate immediate new interventions following falls for Resident (R)16, R10, R7, and R32. Findings included: - Resident (R)16's Physician Orders, dated 09/11/23, included diagnoses of muscle spasms, sprain of the left ankle, left hand pain, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), left and right shoulder pain, and obesity (severe overweight). The admission Minimum Data Set, (MDS) dated [DATE], documented the resident with Brief Interview for Mental Status, score of 13, indicating cognitively intact. She required extensive assistance of staff for bed mobility, transfers, toilet use, and walking in the room. The resident used a walker and wheelchair as mobility devices. Her balance during transition was not steady but she was able to stabilize without staff assistance. She had no functional limitation in her range of motion of her upper or lower extremities. The resident did not receive therapy services nor restorative nursing program and did not experience any falls. The Quarterly MDS, dated 07/25/23, documented changes which included a BIMS score of 12, indicating moderate cognitive impairment. The resident experienced one fall without major injury. The Care Plan, (CP) dated 08/12/23, directed staff the resident was at risk of falls related to muscle spasms, cataracts, rheumatoid arthritis, chronic pain, neuropathy (nerve damage or impairment), dependence on oxygen, morbid obesity, hypertension (elevated blood pressure), and deformity of the resident's left finger. The interventions included the following with their initiation date: 1. Educate the resident about safety reminders and what to do if a fall occurs. Date Initiated: 03/07/2022. 2. Dysom (skid resistant) in wheelchair. Date Initiated: 04/10/23. 3. Check area before the resident starts to transfer to assure there is nothing on the floor that she could trip on. The resident's bed removed for more space in the room due to the resident sleeping in the recliner. Date initiated: 04/16/23. 4. Allow for rest breaks. Date Initiated: 05/16/23. 5. Assure adequate lighting. Date Initiated: 05/16/23. 6. Position the bed in a low position when not giving care. Date Initiated 05/16/23. 7. Consult the Physician for physical therapy (PT) or occupational therapy (OT) as needed (PRN). Date Initiated: 05/16/23. 8. Ensure the call bell is within the resident's reach. Date Initiated 05/16/23. 9. Ensure wheels are locked on the resident's wheelchair during transfers. Date Initiated 05/16/23. Review of the Electronic Medical Record, (EMR), Progress Notes, dated 01/2023 through 06/2023, revealed the resident experienced falls on 01/24/23, 01/25/23, 04/08/23, 04/16/23, and 05/24/23. The facility's Fall Investigation Follow-up, for the above falls documented the facility lacked a thorough investigation to determine the root cause and contributing factors of five of the six falls the resident experienced. Additionally, the facility failed to initiate an immediate appropriate intervention to prevent further falls for four of the above five falls, on 01/24/23, 01/25/23, 04/08/23, and 05/24/23. On 09/18/23 at 01:13 PM, the resident was in a recliner with her legs elevated. The resident stated she had fallen multiple times and scraped herself up a couple of times. R10 reported last week she had to use the lift to get to the bedside commode. On 09/20/23 at 01:48 PM, Administrative Nurse C, stated staff should complete an assessment of a resident when they fall before the resident is moved. The charge nurse should initiate the investigation and to determine the root cause of the fall and implement an immediate, appropriate, and new intervention to prevent further falls. She confirmed the above findings and agreed the fall investigations lacked a thorough investigation to determine root cause and failed to place immediate new interventions to prevent further falls. The facility policy, Falls and Fall Prevention, dated 01/16/22, documentation included interventions determined to be needed are to be put in place, as soon as possible to protect the resident, and should document the interventions on the care plan. The facility failed to thoroughly investigation of the resident to determine contributing factors and causes of falls to implement appropriate immediate new interventions to prevent further falls. - Resident (R)10's Physician Orders, dated 08/21/23, documentation included diagnoses of hypertension (high blood pressure), poly-osteoarthritis (when at least five joints are affected with arthritis), osteoporosis (brittle and fragile bones), disorder of bone density and structure, insomnia (inability to sleep), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change in Status Minimum Data Set, (MDS) dated [DATE], documented the resident rarely/never understood. She required extensive assistance of staff for bed mobility and transfers. Walking did not occur. Her balance during transition was not steady. She required staff assistance to stabilize. The resident had no functional limitation in range of motion of upper or lower extremities and used a wheelchair as an assistive mobility device. The resident experienced two or more falls with no major injury. She was always incontinent of bowel and bladder. The Care Plan, (CP), dated 08/10/23, identified the resident was at risk for falls. Guidance to staff included the following: 1. Hi/Low bed with a fall mat on the floor, initiated 09/08/20. 2. Ensure the resident is wearing appropriate footwear that provides a non-skid sole, initiated 09/08/20. 3. Assure adequate lighting, initiated 05/09/23. (However, the progress notes revealed the resident fell out of her wheelchair while staff propelled her.) 4. Keep the resident's bed in a low position when not giving care, initiated 05/09/23. 5. Ensure the resident's call light is within reach, initiated 05/09/23. (However, the progress notes revealed the resident fell out of her wheelchair while staff propelled her.) Review of the resident's Progress Notes, dated 05/09/23 at 07:13 PM, documentation included the staff propelled the resident in her wheelchair (w/c) into the living room. As they entered the living room, she leaned forward and fell out of her chair and onto the floor. It was noted that she had lost one of her shoes. The facility lacked a thorough fall Investigation, to determine the root cause and contributing factors of the fall on 05/09/23. The interventions placed at the time of the fall were unrelated to the fall that occurred, therefore did not address the actual causes of the fall. On 09/18/23 at 03:02 PM, Licensed Nurse (LN) F, stated the resident fell when staff was pushing her in the w/c, and she lunged forward. Staff had the resident sent to the hospital for evaluation. LN F reported the resident had pedals on her w/c, but the resident would remove her feet off the pedals. LN F stated that when a resident falls, the charge nurse should assess the resident, initiate a falls investigation to determine the root cause of the fall and review and revise the care plan with a relevant, immediate intervention to mitigate the identified causes that contributed to the fall to prevent further falls. On 09/20/23 at 01:48 PM, Administrative Nurse C, stated staff should complete an assessment of a resident when they fall before the resident is moved. The charge nurse should initiate the investigation and to determine the root cause of the fall and implement an immediate, appropriate, and new intervention to prevent further falls. She confirmed the above findings and agreed the fall investigations lacked a thorough investigation to determine root cause and staff failed to review and revise the care plan with appropriate, immediate, new interventions to prevent further falls. The facility policy, Falls and Fall Prevention, dated 01/16/22, documentation included interventions determined to be needed are to be put in place, as soon as possible to protect the resident, and should document the interventions on the care plan. The facility failed to thoroughly investigation of the resident to determine contributing factors and causes of falls to implement appropriate immediate new interventions to prevent further falls.

- R7's pertinent diagnoses from the Electronic Health Record (EHR) documented OSA (obstructive sleep apnea - a condition in which a person cannot maintain an open airway while sleeping). The 10/12/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required limited assistance of one staff for dressing and personal hygiene, otherwise was independent with cares. The 10/12/22 Care Area Assessment (CAA) lacked documentation related to CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with OSA) use. The 07/11/23 Quarterly MDS documented a BIMS score of 15, indicating intact cognition. The resident required extensive assistance of one to two staff all cares. The 09/19/23 Care Plan documented that R7 utilized a CPAP at night and instructed staff to clean the CPAP machine every day but lacked instructions for storage of CPAP machine or associated equipment. R7's EHR Physician Orders included on 04/27/22, revealed CPAP use every night with instructions to wash face and apply mask, then fill water chamber with distilled water. Additional orders for every morning for staff to remove mask from headgear and tubing and clean with warm soapy water and allow to air dry. Additionally, orders documented for staff to clean tubing with warm soapy water and to flush inside of tubing with warm soapy water, then reconnect the tubing to the machine and turn the machine on to air dry inside of tubing. On 09/18/23 at 01:01 PM, R7 observed resting in recliner with a CPAP mask draped across the bed post and the nasal mask in direct contact with the bed post. In addition, there were two unlabeled jugs containing an unknown clear liquid stored upright on the floor between the bed and the bedside table. On 09/19/23 at 11:10 AM, R7's room observed to have a CPAP mask draped across the bed post and the nasal mask in direct contact with the bed post. There was one unlabeled jug containing an unknown clear liquid stored directly on the floor between the bed and the bedside table, and one unlabeled jug containing an unknown clear liquid laying sideways on the floor between the bed and the bedside table. On 09/20/23 at 08:11 AM, R7's room observed to have a CPAP mask draped across the bed post with the nasal mask in direct contact on the resident's bed post, and one unlabeled jug containing an unknown clear liquid sitting upright on the floor between the bed and the bedside table and one unlabeled jug containing an unknown clear liquid laying sideways on the floor between the bed and the bedside table. On 09/20/23 at 02:00 PM, Certified Nurse Aide (CNA) D revealed that CNAs would get R7 up for the morning and take off his CPAP mask but denied knowledge of care of the equipment. On 09/20/23 at 03:59 PM, Administrative Nurse C revealed that the CNAs were expected to clean the CPAP and tubing/mask every morning and the tubing and mask should be stored in a bag. Administrative Nurse C was unable to describe the cleaning procedure for the CPAP tubing/mask. Further stated that bottles of distilled water for the CPAP should be labeled with contents and open/expiration dates and stored off the floor for infection control concerns. On 09/21/23 at 08:50 AM, Licensed Nurse (LN) F revealed CNAs were responsible for AM cares including taking the resident's CPAP machine off as well as care of the equipment. The CPAP humidifiers were to be filled with distilled water. Staff should not store distilled water on the floor, but rather on a shelf somewhere inside the resident's room. LN F stated that the CPAP masks/tubing should be stored in a way that they can be kept sanitary and clean and not touching the headboard and/or footboard of the resident's bed. The tubing and mask should be cleaned every day with isopropyl alcohol swabs and not with soapy water. The facility's Maintenance and Cleaning of Nebulizers / CPAP policy, dated 04/2022, lacked instructions specific to CPAP machine care and maintenance. The facility's Infection Control policy, dated 05/2021, documented that the facility has an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection, but lacked instructions specific to cleaning or care of respiratory equipment. The facility failed to provide infection control measures related to respiratory care consistent with professional standards of care for R7, regarding the use and cleaning of the CPAP machine. This deficient practice places R7 at increased risk for development of respiratory complications and respiratory specific infections. - R31's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 02/01/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The resident was independent with all cares. The 02/01/23 Care Area Assessment (CAA) lacked documentation related to inhaled medication use. The 07/13/23 Quarterly MDS documented a BIMS of 13, indicating intact cognition. The resident required supervision and setup for all cares. The 09/21/23 Care Plan documented an entry on 02/07/23 that R31 was at risk for respiratory distress related to disease process of COPD and instructed staff to administer medications as ordered and to monitor resident for effectiveness. R31's Physician Orders included Ipratropium-Albuterol Sulfate (a medication used to open and relax airway structures), 0.5-2.5 milligrams (mg) in 3 milliter (mL), to be inhaled orally via nebulizer, every six hours as needed for for shortness of air and wheezing related to COPD, ordered 05/22/23. On 09/18/23 at 02:26 PM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/19/23 at 01:50 PM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/20/23 at 10:00 AM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/20/23 at 03:59 PM, Administrative Nurse C stated that the expectation for staff was that after breathing treatments were completed, the nebulizer chamber should be rinsed with water. On 09/21/23 at 08:50 AM, Licensed Nurse (LN) F revealed that Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) do not do anything with the nebulizers as it is a nursing responsibility to administer treatments and care for the equipment. LN F stated that in between treatments, nebulizers should be rinsed out without being disassembled and set on the counter in the room in preparation for the next treatment. After the last treatment of the day, the nebulizers were to be disassembled, rinsed out with water, and set on a paper towel to dry overnight. The facility's Maintenance and Cleaning of Nebulizers / CPAP policy, dated 04/2022, documented that after each treatment, nebulizers were to be disassembled and rinsed under a strong stream of water, shaken dry, placed on a paper towel, covered with another paper towel, and allowed to air dry. Once dry, reassembled for the next treatment. Further documented that twice weekly, nebulizer was to be disassembled and soaked for 30 minutes in a liquid disinfectant (one-part white vinegar, one-part water), rinsed with water, and allowed to air dry between the folds of paper towels or a clean hand towel. When thoroughly dry, store in a plastic bag until ready for use. The facility failed to provide infection control measures related to respiratory care consistent with professional standards of care for R31, regarding the use and cleaning of the nebulizer equipment. This deficient practice places R31 at increased risk for development of respiratory complications and respiratory specific infections. - R9's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic bronchitis (long term inflammation of the large airways in the lungs) and cough. The 10/12/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with all cares. The 10/12/22 Care Area Assessment (CAA) lacked documentation related to inhaled medication use. The 07/11/23 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition. The resident required supervision and setup for all cares. The 09/19/23 Care Plan documented an entry on 04/10/23 that R9 had altered respiratory status related to diagnosis of chronic bronchitis and instructed staff to administer breathing treatments as ordered and to monitor the resident for changes in respiratory status. R9's Physician Orders included Albuterol Sulfate (a medication used to open and relax airway structures), 2.5 milligrams (mg) in 0.5 milliter (mL) to be inhaled orally, via nebulizer, four times per day, for shortness of air and wheezing, related to chronic bronchitis, ordered 10/11/21. On 09/18/23 at 04:45 PM, R9 revealed staff bring the medicine to him and put it in the nebulizer, turn the machine on, then leave. At the completion of his treatment, he turns the machine off and sits the nebulizer on the over-the-bed table where it sits until the next treatment. On 09/18/23 at 04:45 PM, R9's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid observed in the nebulizer chamber. On 09/19/23 at 01:49 PM, R9's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid observed in the nebulizer chamber. On 09/20/23 at 08:07 AM, R9's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid observed in the nebulizer chamber. On 09/20/23 at 03:59 PM, Administrative Nurse C stated that the expectation for staff was that after breathing treatments completed, staff should rinse the nebulizer chamber with water. On 09/21/23 at 08:50 AM, Licensed Nurse (LN) F revealed that Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) do not do anything with the nebulizers as it is a nursing responsibility to administer treatments and care for the equipment. LN F stated that in between treatments, nebulizers should be rinsed out without being disassembled and set on the counter in the room in preparation for the next treatment. After the last treatment of the day, the nebulizers should be disassembled, rinsed out with water, and set on a paper towel to dry overnight. The facility's Maintenance and Cleaning of Nebulizers / CPAP policy, dated 04/2022, documented that after each treatment, nebulizers were to be disassembled and rinsed under a strong stream of water, shaken dry, placed on a paper towel and covered with another paper towel and allowed to air dry. Once dry, reassembled for the next treatment. Further documented that twice weekly, nebulizer was to be disassembled and soaked for 30 minutes in a liquid disinfectant (one-part white vinegar, one-part water), rinsed with water, and allowed to air dry between the folds of paper towels or a clean hand towel. When thoroughly dry, store in a plastic bag until ready for use. The facility failed to provide respiratory care consistent with professional standards of care for R9, regarding the use and cleaning of the nebulizer equipment, to prevent possible respiratory infection. - R31's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 02/01/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The resident was independent with all cares. The 02/01/23 Care Area Assessment (CAA) lacked documentation related to inhaled medication use. The 07/13/23 Quarterly MDS documented a BIMS of 13, indicating intact cognition. The resident required supervision and setup for all cares. The 09/21/23 Care Plan documented an entry on 02/07/23 that R31 was at risk for respiratory distress related to disease process of COPD and instructed staff to administer medications as ordered and to monitor resident for effectiveness. R31's Physician Orders included Ipratropium-Albuterol Sulfate (a medication used to open and relax airway structures), 0.5-2.5 milligrams (mg) in 3 milliter (mL), to be inhaled orally via nebulizer, every six hours as needed for for shortness of air and wheezing related to COPD, ordered 05/22/23. On 09/18/23 at 02:26 PM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/19/23 at 01:50 PM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/20/23 at 10:00 AM, R31's room observed to have an intact nebulizer sitting on the over-the-bed table with an unknown clear liquid in the nebulizer chamber. On 09/20/23 at 03:59 PM, Administrative Nurse C stated that the expectation for staff was that after breathing treatments were completed, the nebulizer chamber should be rinsed with water. On 09/21/23 at 08:50 AM, Licensed Nurse (LN) F revealed that Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) do not do anything with the nebulizers as it is a nursing responsibility to administer treatments and care for the equipment. LN F stated that in between treatments, nebulizers should be rinsed out without being disassembled and set on the counter in the room in preparation for the next treatment. After the last treatment of the day, the nebulizers were to be disassembled, rinsed out with water, and set on a paper towel to dry overnight. The facility's Maintenance and Cleaning of Nebulizers / CPAP policy, dated 04/2022, documented that after each treatment, nebulizers were to be disassembled and rinsed under a strong stream of water, shaken dry, placed on a paper towel, covered with another paper towel, and allowed to air dry. Once dry, reassembled for the next treatment. Further documented that twice weekly, nebulizer was to be disassembled and soaked for 30 minutes in a liquid disinfectant (one-part white vinegar, one-part water), rinsed with water, and allowed to air dry between the folds of paper towels or a clean hand towel. When thoroughly dry, store in a plastic bag until ready for use. The facility failed to provide respiratory care consistent with professional standards of care for R31, regarding the use and cleaning of the nebulizer equipment, to prevent possible respiratory infection. The facility reported a census of 33 residents. Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent cross contamination and the spread of infection in the laundry and throughout the facility. Furthermore, the facility failed to perform required hand hygiene between residents during the delivery of clean linen and passing ice water. Additionally, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection for three residents (R)9, R31, and R7. Findings included: - On 09/21/23 at 11:06 AM, the laundry tour with Laundry/Housekeeping staff I, and Assistant Maintenance Supervisor J, revealed the following concerns: 1. The soiled linen room/sorting room lacked available Personal Protective Equipment (PPE) goggle/face shield for sorting soiled clothing and linens. 2. The laundry processing area had three unsanitizable wired laundry baskets due to split rubber gaskets around the top of the baskets and rust on the wires. One basket had a folded blanket and five pillows, in direct contact with the basket. Another basket had a towel laid across the top of the basket. The articles of clothing and linen were reported as being clean by laundry/housekeeping staff I. 3. The clean linen room with bare wood exposed on four shelves which resulted in unsanitizable surfaces. The bare wood surfaces were in direct contact with the clean linen. On 09/21/23 at 11:06 AM, Laundry/Housekeeping staff I, stated she had dropped and broke her goggles a week prior and had not used eye protection when sorting laundry since that time. She verified the above findings. On 09/21/23 at 11:20 AM, Assistant Maintenance Supervisor J, confirmed the above findings. The facility's policy for Infection Control, dated 05/2021, documentation included the facility shall use methods for transport and storing of clean linen and laundry that will ensure the cleanliness of the linens and laundry. The facility failed to handle, store, process, and transport linens so as to prevent cross contamination and the spread of infection in the laundry.

The facility reported a census of 37 with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure staff administered Tylenol (pain medication) as ordered by the physician for Resident (R)12. Findings include: - R12's Physician's Orders dated 09/10/21 included a diagnosis of pain, unspecified, and an order for Tylenol 650 milligrams (mg) one tablet by mouth three times a day. The Care Plan dated 11/11/21 informed staff R12 had arthritis in the neck, low back pain, and right shoulder pain. R12 received Tylenol 325 mg two tabs every eight hours for pain. The Electronic Medication Administration Record (EMAR) for September 2021 revealed staff failed to give R12 the 05:00 AM dose on five days. The October 2021 MAR lacked documentation of administration of the Tylenol for 9 days. The November 2021 MAR lacked documentation staff administered the Tylenol on nine days Observed on 12/07/21 at 11:59 AM, revealed R12 sat in the television area, watching the staff and other residents, without indications of pain. During an interview with Administrative Nurse B on 12/07/21 at 03:40 PM, she expected the nurses and or the Certified Medication Aide (CMA) to document administrations on the EMAR and did not know why the Tylenol was not documented. Interview with Consultant Staff C on 12/08/21 at 01:34 PM indicated he did not include missing medicaation documentation in his monthly review. The Medication Administration policy reviewed January 2021 documented Every attempt is made to give medication according to the stated time or within one hour and all medications are charted when given. The facility failed to document the administration of Tylenol for R12 as ordered by the physician.

- R12's signed physician orders dated 09/10/21 revealed the diagnosis of hypertension (HTN, elevated blood pressure). The Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. The resident required one staff assistance with Activities of Daily Living (ADL). The resident received antipsychotic and antidepressant medications 7 days of the 7-day observation period. A gradual dose reduction attempted on 02/04/21. The 09/27/21 Quarterly MDS revealed no significant changes since the 03/27/21 MDS. Review of the 11/11/21 Care Plan revealed R12 had HTN and received Metoprolol Tartrate (antihypertensive medication) 25 milligrams (mg) twice daily (BID) for HTN and the staff were to monitor for side effects such as orthostatic hypotension (blood pressure dropping with change of position) and tachycardia (increased heart rate) and report significant changes to the physician. The staff were to monitor the resident for malignant hypertension (very high blood pressure that comes on suddenly and quickly) such as headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (dyspnea). Another intervention included the staff were to obtain the residents blood pressure daily. The Physician Order dated 03/19/21 revealed an order for Metoprolol Tartrate Tablet 25 mg BID for hypertension and to hold the medication if the residents systolic (pressure in the arteries when your heart beats) blood pressure was less than 90 millimeters of mercury (mmHg). Review of the Medication Administration Record MAR from 01/01/21 through 12/07/21 indicated the resident's blood pressures ranged from 110/64 mmHg to 142/60 mmHg. All readings were within the parameters ordered by the physician and the MAR indicated the staff held the Metoprolol medication 11 times (01/20/21, 07/24/21, 09/13/21, 09/14/21, 09/15/21, 09/16/21, 09/20/21, 09/30/21, 10/08/21, 10/31/21, and 11/21/21) with no rationale documented for each. The Medication Administration Record revealed Tylenol 650 mg give 1 tab every 8 hours for Arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement) revealed the following dates R12 did not receive the medication as ordered by the physician. The following dates indicated the staff did not administer R12's 05:00 AM Tylenol 650 mg for five days in September 2021 (3, 21, 23, 24, and 20), for nine days in October 2021 (1, 14, 18, 23, 26, 27, 28, 29, and 30), and nine days in November 2021 (1, 14, 18, 23, 26, 27, 28, 29, and 30). The Consulting Pharmacist did not identify the lack of administration of the Metoprolol and scheduled Tylenol medication during his Monthly Medication Regimen Review report from 12/27/20 to 11/28/21. On 12/07/21 at 07:22 AM the resident sat in the dining room eating her breakfast with hands shaking, but ate independently. On 12/08/21 at 10:08 AM Licensed Nurse G revealed she did not know why the nurse held the Metoprolol if the parameters were to hold if the resident's systolic blood pressure was less than 90 (mmHg) and all her blood pressure readings were within the physician's parameters. On 12/07/21 at 03:40 PM Administrative Nurse B reported she expected the nurse or certified medication aide (CMA) to document on the MAR when giving the medication and if for some reason the medication was not given, and to document a reason why it was held. She had no answer why it was not given on those days unless they misunderstood the symbols such as the less than 90, they thought it should be greater than 90. On 12/08/21 at 01:34 PM Consulting Pharmacist C reported he had at different times over the years reported holes in the MARs and missing documentation but not lately and he did not look at the parameters. He did look for blood pressure or pulse but was more likely to look at them giving too much medication not the parameters and stated he missed them. The Pharmacy Services policy reviewed December 2020 documented The licensed pharmacist will review the drug regimen of each resident monthly .Any irregularities will be reported to the attending physician, the Director of Nursing, and the Medical Director . The facility failed to ensure the Consultant Pharmacist identifed the lack of administration of blood pressure medication and lack of adminstration of pain medication (Tylenol) as per the physician orders for R12, without a rationale as to why they were not administered. The facility had a census of 37 residents, with 12 residents sampled, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the pharmacist identified and reported missing documentation concerning the lack of administration of scheduled pain medication (Tylenol) as ordered and blood pressure medications for Resident (R)12, and the lack of an end date for as needed (PRN) psychotropic (relating to or denoting drugs that affect a person's mental state) medications administered past the 14 day regulatory requirement for R22. Findings included: - Resident (R)22's signed physician orders dated 12/02/21 revealed the following diagnoses: major depressive disorder (major mood disorder), vascular dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with restlessness and agitation. The Significant Change in Status Minimum Data Set (MDS) dated 07/16/21 revealed the resident had severe cognitive impairment and rarely understood what was said. The resident had hallucinations and delusions with verbal and physical behaviors 1-3 days a week. The resident wandered in the facility 1-3 days a week. The resident required extensive assistance of two staff for daily care and assistance of one with eating. Medications included antipsychotic, antianxiety and opioid medications 7 days of the 7-day observation period. Review of the Quarterly MDS dated 11/04/21 revealed the resident had no hallucinations or delusions. The resident had verbal and physical behaviors though no longer wandered in the facility. The 07/16/21 Care Area Assessment (CAA) regarding Cognitive Loss/Dementia revealed R22 had Alzheimer's dementia, late onset. Her cognitive loss was severe. R22 needed extensive assistance with activities of daily living (ADL) and decision making due to the cognition loss. She had behavioral episodes and not understanding surroundings at times. The 07/16/21 CAA regarding Behavioral Symptoms revealed R22 had episodes of behaviors that she could be physically aggressive, curse, be verbally aggressive, smear or throw feces at caregivers during incontinence episodes. R22 did not like to bathe. Behaviors could be related to the severe cognitive impairment and not understanding surrounds, what was going on, and what she was doing. The 07/16/21 CAA regarding Psychotropic Medications revealed R22 was at risk for having adverse side effects from the psychotropic medications she received: Seroquel (antipsychotic), Buspirone (antianxiety), and as needed (PRN) Ativan (antianxiety). The staff were to complete weekly side effect monitoring logs, as well as monthly pharmacy consult reviews. The Care Plan dated 08/20/21 revealed R22 had Alzheimer's Disease and was moderately/severely impaired cognitively. R22 was not always able to communicate her needs. She could speak, but did not always make sense, and her interaction with others could be limited/impaired due to her cognitive status. The Physician Order dated 10/12/20 revealed Ativan tablet 1 milligram (mg) give 0.5 mg by mouth every four hours as needed (PRN) for agitation, restlessness, and anxiety related to restlessness. The 10/12/21 Physician Order for PRN Ativan did not have an end date. Observation on 12/07/21 at 03:56 PM revealed the resident became very restless in her wheelchair. Certified Nursing Assistant (CNA) E and CNA D propelled the resident to the bathhouse for toileting. The staff explained to the resident they were going to use the lift to get the resident out of her wheelchair. The sling was placed around the resident with resident not understanding what staff were doing. The resident was angry and agitated, and yelling at staff. On 12/08/21 at 09:30 AM revealed the resident sat at the nurse's station working with an activity board. The resident was calm with no agitation noted. On 12/08/21 at 10:50 AM CNA F reported the resident had many behaviors. R22 would fight whatever staff tried to do with her. CNA F said if it was not the resident's idea and the resident was in a mood, R22 would hit at staff with her fists. CNA F stated the nurse had to give medication to R22 before the staff could give her a bath. Toileting the resident made the resident mad and staff had to keep talking to her to distract her from the care being given. On 12/08/21 at 12:10 PM Licensed Nurse (LN) G reported she did not know of the regulation limiting the use of psychotropic medications to 14 days and did not think the physicians were aware of that either. The resident had verbal and physical behaviors and could be aggressive with care given. The resident hated getting bathed or having incontinent care done. During an interview on 12/07/21 at 03:50 PM Administrative Nurse B reported she did not know how the resident had remained with a PRN order for Ativan longer than the 14 days allowed. She found no physician order to continue or discontinue and did not know why the pharmacist did not catch that during his review. On 12/08/21 at 01:40 PM Consulting Pharmacist C reported he was not aware of the regulation limiting the psychotropic medications to 14 days. He reported he does not review the physician orders so did not know how he would be able to catch that. It would be very difficult for him to monitor the duration of the PRN medications. The Pharmacy Services policy reviewed December 2020 documented The licensed pharmacist will review the drug regimen of each resident monthly .Any irregularities will be reported to the attending physician, the Director of Nursing, and the Medical Director . The facility failed to ensure the Consultant Pharmacist monitored and identified PRN psychotropic medications for an appropriate end date.

The facility census totaled 37 residents, with 12 in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the efficacy of blood pressure medications for Resident (12), when stafff failed to administer the medicaiton as ordered, and failed to document why the staff did not administer the medication as ordered. Findings included: - R12's signed physician orders dated 09/10/21 revealed the diagnosis of hypertension (HTN, elevated blood pressure). The Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. The resident required one staff assistance with Activities of Daily Living (ADL). The resident received antipsychotic and antidepressant medications 7 days of the 7-day observation period. A gradual dose reduction attempted on 02/04/21. The 09/27/21 Quarterly MDS revealed no significant changes since the 03/27/21 MDS. Review of the 11/11/21 Care Plan revealed R12 had HTN and received Metoprolol Tartrate (antihypertensive medication) 25 milligrams (mg) twice daily (BID) for HTN and the staff were to monitor for side effects such as orthostatic hypotension (blood pressure dropping with change of position) and tachycardia (increased heart rate) and report significant changes to the physician. The staff were to monitor the resident for malignant hypertension (very high blood pressure that comes on suddenly and quickly) such as headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (dyspnea). Another intervention included the staff were to obtain the residents blood pressure daily. The Physician Order dated 03/19/21 revealed an order for Metoprolol Tartrate Tablet 25 mg BID for hypertension and to hold the medication if the residents systolic (pressure in the arteries when your heart beats) blood pressure was less than 90 millimeters of mercury (mmHg). Review of the Medication Administration Record MAR from 01/01/21 through 12/07/21 indicated the resident's blood pressures ranged from 110/64 mmHg to 142/60 mmHg. All readings were within the parameters ordered by the physician and the MAR indicated the staff held the Metoprolol medication 11 times (01/20/21, 07/24/21, 09/13/21, 09/14/21, 09/15/21, 09/16/21, 09/20/21, 09/30/21, 10/08/21, 10/31/21, and 11/21/21) with no rationale documented for each date not administered. On 12/07/21 at 07:22 AM R12 sat in the dining room eating her breakfast. Her hands shook but she ate independently. On 12/08/21 at 10:08 AM Licensed Nurse G revealed she did not know why the nurse held the Metoprolol if the parameters were to hold if the resident's systolic blood pressure was less than 90 (mmHg) and all her blood pressure readings were within the physician's parameters. On 12/07/21 at 03:40 PM Administrative Nurse B reported she expected the nurse or certified medication aide (CMA) to document on the MAR when administering the medication and if, for some reason, the medication was not given, and to document a reason why the staff held the medication administration She had no answer why it was not given on those days unless the staff misunderstood the symbols such as the less than 90, and they thought it should be greater than 90. On 12/08/21 at 01:34 PM Consulting Pharmacist C reported he had at different times over the years reported holes in the MARs and missing documentation but not lately and he did not look at the parameters. He did look for blood pressure or pulse but was more likely to look at them giving too much medication not the parameters and stated he missed them. The Pharmacy Services policy reviewed December 2020 documented The licensed pharmacist will review the drug regimen of each resident monthly .Any irregularities will be reported to the attending physician, the Director of Nursing, and the Medical Director . The facility failed to follow the physician's orders for blood pressure medications for R12 and failed to document why the staff did not administer the medication as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure Resident (R)22's did not receive unnecessary medications when staff admnistered an as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication from an order dated 10/12/20 (almost 14 months prior and without a duration for use) and the staff continued to administer the PRN psychotropic medication. The medical record lacked a physician rationale for the continued adminsitration of the PRN psychotropic medication, Ativan, for R22. Findings included: - Resident (R)22's signed physician orders dated 12/02/21 revealed the following diagnoses: major depressive disorder (major mood disorder), vascular dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with restlessness and agitation. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and rarely understood what was said. The resident had hallucinations and delusions with verbal and physical behaviors 1 to 3 days a week and wandered in the facility 1-3 days a week. The resident required extensive assistance of two staff for daily care. Medications included antipsychotic, antianxiety and opioid medications 7 days of the 7-day observation period. Review of the Quarterly MDS dated 11/04/21 revealed the resident had no hallucinations or delusions. The resident had verbal and physical behaviors though no longer wandered in the facility. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/16/21 revealedbR22 had late onset Alzheimer's dementia and noted her cognitive loss was severe. R22 needed extensive assistance with activities of daily living (ADL) and decision making due to the cognition loss. She had behavioral episodes and did not understand surroundings at times. The Behavioral Symptoms CAA revealed R22 had episodes of behaviors and noted she could be physically aggressive, curse, verbally aggressive, and smear or throw feces at caregivers during incontinence episodes. R22 did not like to bathe. Her behaviors could be related to the severe cognitive impairment and not understanding surroundings or what was going on, and what she was doing. The Psychotropic Medications CAA revealed R22 was at risk for having adverse side effects from the psychotropic medications she recieved. She received Seroquel (antipsychotic), Buspirone (antianxiety), and as needed (PRN) Ativan (antianxiety). The weekly side effect monitoring logs were completed, as well as monthly pharmacy consult reviews. The 08/20/21 Care Plan revealed R22 had Alzheimer's Disease and was moderately/severely impaired cognitively, R22 could not always communicate her needs, she could speak, just did not always make sense. Her interaction with others could be limited/impaired due to her cognitive status. The 10/12/20 Physician Order revealed an order for Ativan (antianxiety) tablet 1milligram (mg), staff were to administer 0.5 mg by mouth every four hours as needed (PRN) for agitation, restlessness, and anxiety related to restlessness. The order for the PRN antipychotic Ativan was dated almost 14 months prior, with no updated order or rationale for continuation of the PRN antipychotic in R22's clinical record, to indicate use past the 14 day regulatory requirement. On 12/07/21 at 03:56 PM revealed the resident becoming very restless in her wheelchair. The resident was wheeled to the bath house by Certified Nurse Aide (CNA) E and CNA D to toilet the resident. Staff explained to the resident they were going to use the lift to get the resident out of her wheelchair. The sling was placed around the resident with resident not understanding what staff were doing. The resident appeared angry and agitated and yelled at the staff during cares. On 12/08/21 at 09:30 AM revealed the resident sat at the nurse's station working with and activity board. The resident appeared calm with no agitation noted. On 12/08/21 at 10:50 AM CNA F reported the resident had many behaviors and R22 would fight during most cares. CNA F stated if it was not the residents idea and R22 was in a mood, R11hit teh staff with her fists. The nurse had to give her medication before we could give her a bath. CNA F stated toileting the resident made R22 mad and staff talked to the ressident to try and distract her from the care being given. On 12/08/21 at 12:10 PM Licensed Nurse G reported she did not know of the regulation limiting the use of psychotropic medications to 14 days and did not think the physicians knew of that either. The resident had verbal and physical behaviors and could be aggressive with care given. The resident hated getting a bath or having incontinent cares completed. During an interview on 12/07/21 at 03:50 PM Administrative Nurse B reported she did not know how the resident had remained with a PRN order for Ativan longer than the 14 days allowed. She found no physician order to continue or discontinue and did not know why the pharmacist did not catch that during his review. On 12/08/21 at 01:40 PM Consulting Pharmacist C reported he did not know of the regulation limiting the psychotropic medications to 14 days. He reported he did not review the physician orders so he did not know how he would be able to catch that and said it would be very difficult for him to monitor the duration of the PRN medications. The facility did not provide a policy concerning the use of PRN psychotropic medications as requested on 12/07/21. The facility failed to ensure the PRN psychotropic medication administered to R22's from a 14-month old order, contained a duration of use.

The facility reported a census of 37 residents. Based on observation, interview, and record review the facility failed to ensure staff used Personal Protective Equipment (PPE) appropriately, during toileting cares observation for Resident (R)22. Findings included: - R1's signed Physician Orders dated 10/05/21 revealed the following diagnoses: macular degeneration (progressive deterioration of the retina, bilateral), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (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 Annual Minimum Data Set (MDS) dated 08/11/21 revealed a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The resident had no behaviors. The resident required extensive assistance of two staff with daily care. The resident received an antipsychotic and antianxiety medication 7 days of the 7-day observation period. The Urinary Incontinence and Indwelling Catheter Care Are Assessment (CAA) dated 07/06/21 revealed R22 was always incontinent of bowel and bladder and required extensive assistance with two caregivers for toileting. The Care Plan dated 09/09/20 revealed R22 required assistance to toilet upon rising, before or after meals, mid-afternoon and before going to bed. Staff may provide incontinence care at bedside if R22 was noted to already be soiled. On 12/07/21 at 03:56 PM, observation revealed R22 became very restless in her wheelchair. Certified Nurse Aide (CNA) E and CNA D took R22 to the bath house to be toileted. CNA E pulled R22's pants down and removed her soiled brief. Staff transferred R22 to the toilet. After a short time, a clean brief was placed over R22's legs and CNA E used wet wipes to perform peri care and then pulled up her clean brief and pants all while CNA E wore the same gloves throughout the whole process. CNA E removed her gloves after staff transferred the resident back into her wheelchair. During an interview on 12/07/21 at 04:03 PM CNA E reported she only changed gloves if they were soiled, otherwise she would use the same gloves throughout the whole toileting process. During an interview on 12/07/21 at 03:50 PM Administrative Nurse B stated she expected staff to change gloves and perform good hand hygiene when toileting residents. The Gloving policy reviewed January 2021 documented Remove gloves after perineal care has been completed before continuing (sic) on with resident's care. The facility failed to ensure staff changed gloves appropriately when toileting and performing peri-care for R22.

The facility reported a census of 37 residents with one main kitchen, which prepared and served food for all residents. Based on observation, interview, and record review the facility failed to handle and store food in accordance with professional standards for food service safety when dietary staff did not prepare food for storage or date and store foods in a sanitary manner. Findings included: - On 12/06/21 at 07:40 AM initial tour of main kitchen revealed the following: In the refrigerator the following foods were not dated: shredded cabbage, green peppers, shredded lettuce, cauliflower, and broccoli, there was also a container of carrot salad, a thawed frozen TV dinner, and a plate of brownies all opened and undated. In the freezer there was a bag of unidentifiable frozen meat in a package open to air and undated, and a large bag of frozen dough for rolls open to air and undated. In the dry storage area, there was a large bag of cake mix open and undated. All food items removed and discarded by Certified Dietary Manager (CDM) O. Observation on 12/06/21 at 08:45 AM CDM O placed cooked foods from breakfast in bags for storage. Staff picked up bacon and placed it in a storage bag, moved the pan out of the way, picked up the pan of sausage patties, and placed the patties into a separate storage bag. The staff handled all of the food items, touched the pans, and touched the countertop without changing gloves and/or performing hand hygiene. On 12/06/21 at 09:00 AM CDM O confirmed she expected staff to perform appropriate hand hygiene and appropriately use gloves while preparing or storing cooked foods. She also confirmed stored foods should always be dated when opened. The Food Storage policy reviewed February 2021 documented Food that is removed from the original packaging for storage will be labeled with the contents and dated. The Gloving Use- Dietary policy reviewed January 2021 documented Gloves are to be changed: After they become soiled or .Before beginning a different task . The facility failed to handle and store food in accordance with professional standards for food service safety to prevent the outbreak of foodborne illness.