**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 41's dignity was maintained. This deficient practice placed R41 at risk for impaired dignity and decreased psychosocial well-being. Findings included: - R41's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R41 had severely impaired cognition. The MDS documented R41 was dependent on staff assistance for activities of daily living (ADLs). The MDS documented R41 had bilateral lower extremity impairment of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). R41's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/15/24 documented R41 had a diagnosis of dementia. R41 had memory loss and disorganized thinking. R41's Care Plan dated 03/11/24 documented he preferred his shower twice weekly in the evening. The plan of care documented that staff would break down the tasks into segments for R41 to be more manageable. The plan of care for R41 documented that staff would establish and maintain a routine and would reorient and reassure him as needed. The plan of care also documented staff would support and assist him with problem-solving. On 08/05/24 at 09:09 AM R41 was transferred from his bed to a shower chair with the assistance of Certified Nurse Aide (CNA) O and CNA P with a Hoyer lift (total body mechanical lift). R41 was dressed in a gown that was open in the back, he was unable to sit upright on the shower chair. CNA O placed a small blanket from R41's bed around his waist to his knees. CNA O and CNA P attempted to reposition him on the shower chair by lifting him under his arms and legs. CNA O stated R41 was unable to sit upright on the shower chair, and he usually was given a shower on the bath bed, but another unit was using it at that time. CNA O stated she would have to pull R41 down the hallway backward because R41's feet would get caught under the shower chair or drag on the floor. CNA O pulled R41 down the hallway to the shower room backwards with CNA P attempting to hold R41's feet from dragging on the floor. On 08/07/24 at 09:07 AM, CNA N stated should never be pulled backward down the hallway on a shower chair. CNA N stated a resident should be covered when in the hallways. On 08/07/24 at 09:12 AM, Licensed Nurse (LN) H stated a resident should never be pulled backward, if a person's legs are too long, they should have been put in a reclining shower chair. LN H said residents should be covered appropriately. On 08/07/24 at 10:43 AM, Administrative Nurse D stated if a resident was unable to be pushed forward in the shower chair then it would be safer to pull the resident backward Administrative Nurse D stated she expected the staff to follow the residents' care plan. The facility's Right to Dignity policy dated 11/29/19 documented the facility would promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality. All staff would provide dignity to each resident by maintaining the resident's privacy of body which included. Keeping the resident covered while transporting the resident outside the resident's room. The residents would be undressed and dressed inside the bathing room rather than being transported without full clothing unless otherwise care planned, and a resident has requested it. The facility failed to ensure R41's right to be treated with respect, and dignity when pulled in the hallway backward on a shower chair. This deficient practice placed R41 at risk for negative psychosocial outcomes and decreased dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination for Resident (R)41. This deficient practice placed R41 at increased risk for respiratory infection and complications. Findings included: - R41's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R41 had severely impaired cognition. The MDS documented R41 was dependent on staff assistance for activities of daily living (ADLs). The MDS documented R41 had bilateral lower extremity impairment of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). R41's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/15/24 documented R41 had a diagnosis of dementia. R41 had memory loss and disorganized thinking. R41's Care Plan dated 07/09/24 documented that staff would change the oxygen tubing weekly and as needed. The plan of care documented that staff would monitor the oxygen concentrator to ensure proper operation and clean the filters weekly and as needed. The plan of care documented that staff would monitor his oxygen saturation every shift and report any changes to the physician. The care plan documented the facility would provide education regarding the use of oxygen and would demonstrate proper placement of the oxygen equipment. R41's EMR under the Orders tab revealed the following physician orders: Titrate oxygen via nasal cannula to maintain oxygen saturation above 90 percent every shift dated 06/11/24. On 08/05/24 at 09:09 AM R41 laid on his back on the bed. The bed was in a low position R41 was not wearing an oxygen nasal cannula. A nasal cannula and oxygen tubing were wrapped tightly around the back of a Broda chair (specialized wheelchair with the ability to tilt and recline) in the room. Another nasal cannula and oxygen tubing were draped over the oxygen concentrator next to his bed. On 08/06/24 at 12:24 PM, R41's nasal cannula and oxygen tubing were hung over the top of the oxygen concentrator and rested on the floor behind the concentrator. A black bag was attached to the oxygen concentrator. On 08/06/24 at 02:23 PM, R41 lay on his bed with his eyes closed and a nasal cannula was intact on his face. Oxygen tubing and a nasal cannula were draped over the back of the Broda chair and not placed in the black bag that was attached to the back of the Broda chair. On 08/06/24 at 09:10 AM, Certified Nurse Aide (CNA) N stated all oxygen nasal cannulas should be stored in a bag when not in use. CNA N stated the oxygen nasal cannulas are changed weekly. On 08/06/24 at 09:12 AM, Licensed Nurse (LN) H stated all of the residents who are on oxygen therapy are given containers and bags for oxygen cannulas and nebulizers. LN H stated all oxygen should be placed in bags or canisters when not in use for sanitation, and never wrapped around handles of oxygen canisters or draped over chairs. On 08/06/24 at 10:43 AM, Administrative Nurse D stated she expected the oxygen nasal cannulas to be stored in a sanitary manner. Administrative Nurse D stated the nasal cannulas are changed weekly and a black bag was provided to store the nasal cannula when not in use. Administrative Nurse D said it should never be placed on the floor or draped over a chair. The facility was unable to provide a policy related to sanitary storage of oxygen equipment when not in use. The facility failed to ensure R41's oxygen tubing was stored in a sanitary manner to decrease exposure and contamination. This placed R41 at increased risk for respiratory infection and complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included 15 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to ensure a form of communication was established between the facility and the dialysis center for Resident (R) 3. This deficient practice placed R3 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R3's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dependence on renal dialysis, end-stage renal disease (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), and a need for assistance with personal care. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R3 received hemodialysis services during the observation period. R3's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 06/06/24 documented during the assessment period, R3 required staff assistance for activities of daily living (ADLs). R3 received renal dialysis on Monday, Wednesday, and Friday. R3's Care Plan dated 05/29/24 documented that staff would observe, monitor, and assess the arteriovenous (AV-a surgically created connection between an artery and a vein) for signs or symptoms of infection, compromise, and impairment. R3's EMR under the Orders tab revealed the following physician orders: Dialysis on Monday, Wednesday, and Friday at 10:30 AM dated 05/29/24. R3's clinical record reviewed from 05/29/24 to 08/06/24 lacked evidence of consistent communication between the facility and the dialysis provider. On 08/06/24 at 12:58 PM, R3 walked around in his room without difficulty. On 08/06/24 at 01:55 PM, Licensed Nurse (LN) I stated the facility did not send communication sheets with R3 to dialysis. LN I stated the dialysis provider would call the facility if there had been a change, if lab work had been obtained, or any other changes. LN I stated the facility did not notify the dialysis provider of any pre-dialysis assessments on the days R3 went for dialysis treatment. On 08/06/24 at 02:46 PM, Administrative Nurse D stated she believed that the facility system was to send a dialysis communication sheet with any resident who received dialysis though the dialysis provider did not always return the communication sheets. Administrative Nurse D stated she would have to check with Administrative Nurse E. On 08/06/24 at 03:20 PM Administrative Nurse E stated the facility had stopped sending dialysis communication sheets with the residents to their dialysis providers due to the provider not returning the communication sheet. The facility's undated Hemodialysis Policy documented the facility was to provide excellence in care and services to residents with End-Stage Renal Disease (ESRD) receiving hemodialysis at a certified renal dialysis unit off-site. Coordination of care included Information transmitted to the dialysis unit by the facility prior to dialysis, and information transmitted to the facility by the dialysis unit after dialysis. The facility staff would initiate a written communication form that would accompany the resident off-site to the dialysis unit and return, completed by the dialysis unit staff for every visit. The facility failed to ensure a form of communication was established between the facility and the dialysis center for R3. This deficient practice placed R3 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 57 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 08/06/24 at 01:15 PM the training record on file at the facility for agency Certified Nurses Aid (CNA) M and agency Licensed Nurse (LN) G revealed the following: CNA M's facility-provided credentialing file lacked documented training completed for communication. The file noted he was provided abuse, neglect, and exploitation (ANE), dementia, and infection control training. LN G's facility-provided credentialing file lacked documented training completed for communication. The file noted she was provided abuse, neglect, and exploitation (ANE), and dementia. 08/07/24 at 07:04 AM Administrative Nurse D stated the facility relied on the contracted agency to provide the required education for the agency nursing staff. She stated the facility had not ensured the agency staff had the education and/or training required for direct care staff. The facility was unable to provide a policy related to required education for direct care staff. The facility failed to ensure the completion of the required communication training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 57 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident's rights training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 08/06/24 at 01:15 PM the training record on file at the facility for agency Certified Nurses Aid (CNA) M and agency Licensed Nurse (LN) G revealed the following: CNA M's facility-provided credentialing file lacked documented training completed for resident rights. The file noted he was provided abuse, neglect, and exploitation (ANE), dementia, and infection control training. LN G's facility-provided credentialing file lacked documented training completed for resident rights. The file noted she was provided abuse, neglect, and exploitation (ANE), and dementia training. 08/07/24 at 07:04 AM Administrative Nurse D stated the facility relied on the contracted agency to provide the required education for the agency nursing staff. She stated the facility had not ensured the agency staff had the education and/or training required for direct care staff. The facility was unable to provide a policy related to required education for direct care staff. The facility failed to ensure the completion of the required resident's rights training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 57 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for Resident (R) 32 for terminal diagnosis and pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R32 at risk for inappropriate care planning and care needs. Findings included: - R32's Electronic Medical Record (EMR) under the 'Diagnosis tab documented type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (elevated blood pressure), muscle weakness, atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), and hypothyroidism (condition characterized by decreased activity of the thyroid gland). The Significant Change MDS dated 09/21/22 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded that R32 was on hospice yet did not accurately indicate R32 had a terminal diagnosis with six months or less to live. The Quarterly MDS dated 12/22/22 documented a BIMS score of 15 which indicated intact cognition. The MDS inaccurately recorded that R32 had no pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The Orders tab documented order clarification on 09/19/22 which noted R32 was admitted to hospice on 09/15/22 with a diagnosis of severe coronary heart disease. The Skin Assessment dated 12/16/22 documented a stage two pressure ulcer to left heel with current treatment ordered. The Skin Assessment dated 12/23/22 documented a stage two pressure ulcer to left heel with current treatment ordered. On 02/02/23 at 10:08 AM R32 sat in a wheelchair next to the bed. R32 worn non-skid socks, had a bed cradle on the foot of the bed which also had a low air loss mattress. R32's leg drainage bag on her leg contained light amber urine. On 02/02/23 at 02:54 PM Licensed Nurse (LN) H stated a nurse must use their own judgement when completing an assessment related to falls and/or skin. LN H stated she would never review a previous assessment to see the prior status of the resident, because the current assessment was to reflect what the resident was at the time of current assessment. On 02/02/23 at 03:11 PM Administrative Nurse E stated she reviewed all assessment in each of the residents' clinical record to complete the MDS for each resident. Administrative nurse E stated she was unsure why R32's MDS was coded the way it was, and she said she would have to look at it. The facility's MDS 3.0 Completion policy dated 01/15/23 documented residents were assessed, by using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. The facility failed to accurately reflect the status of R32's terminal diagnosis and existence of a facility acquired pressure ulcer. This placed R32 at risk for inappropriate care planning and care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 56 residents. The sample included 14 residents with two reviewed for incontinence and or catheter (tube inserted into the bladder to drain urine) care. Based on observation, interviews, and record review the facility failed to fully assess, analyze findings, and develop a resident-centered toileting program and/or schedule which addressed Resident (R) 29's urine incontinence. The facility further failed to ensure R32 had current physician's order with a valid indication for an indwelling catheter which remained in place despite recurring urinary tract infections (UTI). This placed the residents at risk for incontinence and/or catheter related complications. Findings included: - R29's Electronic Medical Record (EMR) recorded diagnoses of cerebral infarction (stroke- occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia and hemiparesis following cerebral infarction (weakness or the inability to move on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). R29's admission Minimum Data Set (MDS) dated 09/04/22 Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. She had verbal behaviors directed towards others for one to three days of the look back period. Significantly interfered with her participation in activities and significantly intruded on the privacy or activity of others and disrupted cares and the living environment. The Falls Care Area Assessment dated 09/11/22 recorded R29 had potential for falls due to a history of falls. Use of psychotropic (alters mood or thought) medication and stroke issues. She had cognitive impairment. Her fall assessment score was 13. The CAA documented R29 did not ambulate and required two staff assist with transfers with a gait belt and she sued a wheelchair for mobility. R29's Quarterly MDS dated 12/05/22 recorded R29 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R29 required extensive assistance of one to two staff for most activities of daily living (ADL), extensive assistance of two staff for bed mobility, but was totally dependent on two staff for toileting and transfers. The MDS recorded R29 had no behaviors. The MDS recorded R29 was frequently incontinent of urine but was continent of bowel. The MDS documented R29 had trialed a toileting program since admission but was not currently on a toileting program. R29 had two or more falls since the previous assessment, one with injury. The MDS documented r29 received an antipsychotic medication (medication used to treat major mental disorders), an antidepressant (medication used to treat depression) and a diuretic (medication which promotes the formation and excretion of urine) all seven of the looks back days. The MDS documented a gradual dose had been attempted on 11/14/22. The Care Plan documented R29 had safety/fall risk due to impaired mobility. The plan recorded interventions dated 08/29/22 which directed staff to assure lighting was appropriate, encourage family participation, encourage resident to sue the call light for staff assistance, an update was added on 11/08/22 which directed staff to place a fall mat at the bedside and recorded the resident would work with therapy to gain strength and balance. An update on 12/29/22 directed staff to place a body pillow on R29's right side when she was in bed. The Care Plan dated 08/29/22 recorded R29 required extensive assistance with ADL. The plan dated 08/2922 directed staff R29 required two staff assistances for transfers and directed staff to encourage R29 to stand up tall and look up and to allow R29 time to do it. An intervention dated 08/29/22 directed staff that R29 needed to sue the big bathroom for toileting. It instructed staff she required assistance from two staff for the transfer and to cue her to stand tall and look up and allow her time to do that. The Care Plan dated 08/29/22 recorded R29 had late effects from a stroke and an intervention dated 08/29/22 directed she required staff assistance with toileting but was left blank on the amount of assistance or staff. The plan further directed staff R29 had diabetes (disease that affects the body's ability to use sugar and results in high blood sugar levels) and directed staff to monitor for symptoms which included increased urination. The care plan lacked further direction related to incontinence, or toileting such as frequency or resident specific toileting preferences/schedules. The admission Continence Assessment dated 08/29/22 which was unlocked and remained in progress at the time of the survey recorded R29 did not have an indwelling catheter, had trouble holding her urine and sometimes used pads to protect her clothing due to urine leakage. The assessment recorded the resident had trouble controlling her urine prior to admission for over a year and had urine leakage all the time. The assessment recorded R29 had trouble controlling her urine related to it coming on so fast she could not get to the toilet, but she could tell when she had to urinate. The assessment further recorded she needed assistance in the bathroom with her clothing, getting on and off the toilet, and performing peri cares. The assessment recorded she received antipsychotic/antidepressant medication and had diabetes. The results section which indicated if a post void residual result, a three-day voiding diary completed, physician review of the assessment results, a toileting plan developed and the care plan updated to reflect toileting plan was left blank. The quarterly Continence Assessment dated 12/01/22 but unlocked and in progress at the time of the survey recorded R29 did not have an indwelling catheter, had trouble holding her urine and sometimes used pads to protect her clothing due to urine leakage. The assessment recorded the resident had trouble controlling her urine prior to admission for over a year and had urine leakage all the time. The assessment recorded R29 had trouble controlling her urine due to difficulty managing in the bathroom causing accidents in the bathroom and she could sometimes tell when she had to urinate. The assessment further recorded she needed assistance in the bathroom with her clothing, getting on and off the toilet, and performing peri cares. The assessment recorded she received antipsychotic/antidepressant medication, diuretics, and had diabetes. The results section which indicated if a post void residual result, a three-day voiding diary completed, physician review of the assessment results, a toileting plan developed and the care plan updated to reflect toileting plan was left blank. R29's clinical record lacked evidence of further assessment related to her incontinence and/or development of a toileting program or personalized toileting schedule. An Incident Note dated 11/19/22 at 11:06 AM recorded an investigation was performed regarding the residnet fell in her room. The Certified Nurse Aide (CNA) found R29 on the floor. The Licensed Nurse (PN) observed R29 laying in the prone (on her stomach) position on the floor with R29's head towards the doorway. R29 had new abrasions to her forehead and nose and a hematoma (collection of blood under the skin due to trauma) to the apex of her nose. The root cause was recorded as the resident was trying to take herself to the bathroom. The note recorded the intervention was a reminder for nurses to educate and monitor staff, and re-educate if needed, that R29 needed toileted at least every two hours to assist in preventing falls. It further documented the care plan was appropriate and to continue with current plan and the [NAME] (tool for direct care staff which directed resident needs) was updated as well for CNA staff reminder to toilet resident every two hours to also help with fall prevention. An Incident Note dated 12/29/22 at 12:47 PM recorded an investigation was performed regarding the residnet fell in her room on 12/25/22. The LN entered the room and observed R29 on the floor next to her bed. R29 laid on her stomach with her head turned and her right cheek rested on the floor. R29 was incontinent or urine. The note recorded the root cause was the residnet needed to go to the bathroom. The note documented the intervention was to be sure the body pillow in place on the resident's right side and encourage staff to take R29 to the bathroom when she was tearful to be sure it was not an unmet need. On 02/01/23 at 09:15 AM R29 sat in a wheelchair, next to her bed with a bedside table in front of R29 and a soft touch call light on the bedside table. On 02/02/23 at 01:40 PM Certified Medication Aide (CMA) R stated R29 would cry at times and the cry was most general would indicate R29 wanted to use the bathroom or be changed due to incontinence. CMA R stated R29 was able to let the staff know when she needed to use the bathroom. CMA R stated R29 was on every two-hour toileting. CMA R stated if a resident was a toileting program the staff would find that information of the [NAME] (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change). On 02/02/23 at 01:55 PM Licensed Nurse (LN) G stated R29 would cry at times to alert the staff to her needs. LN G stated he was not sure R29 was on an individualized toileting program, but she was toileted at least every two hours. On 02/02/23 at 03:11 PM Administrative Nurse E stated she was not sure if R29 was on an individualized toileting program to help with prevention of falls. On 02/02/23 at 03:37 PM Administrative Nurse D stated R29's crying was an indication that R29 wanted staff's assistance with something such as toileting, eating, being laid down in bed. Administrative Nurse D stated sometimes R29's crying was loud enough to hear it through a closed door. Administrative Nurse D stated she was not aware of R29 having a recent bowel and bladder assessment to review for possible toileting trends. The facility did not provide a policy related to incontinence care or toileting programs. The facility failed to fully assess, analyze findings, and develop a toileting plan or plan addressing R29 urine incontinence. This placed R29 at increased risk for toileting related falls, and increased incontinence and related complications. - R32's electronic medical record (EMR) diagnosis tab documented type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (elevated blood pressure), muscle weakness, atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), retention of urine, and hypothyroidism(condition characterized by decreased activity of the thyroid gland). The Significant Change MDS dated 09/21/22 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded that R32 was on hospice yet did not indicate R32 had six months or less to live. The Quarterly MDS dated 12/22/22 documented a BIMS score of 15 which indicated intact cognition. The MDS recorded that R32 had no pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The Urinary Incontinence Care Area Assessment (CAA) dated 09/21/22 documented R32 had a foley catheter. The Care Plan lacked any documentation regarding the catheter including care and reason for continued indwelling catheter. A Physician Order dated 08/30/22 directed oxybutynin chloride extended release 24 hours (medication used to treat bladder muscle spasms to reduce the urge and frequency of urination)15 milligrams (mg) give one tablet by mouth daily for retention of urine was discontinued 09/06/22. A Physician Order dated 08/30/22 methenamine hippurate tablet one gram (gm) give one tablet by mouth in the morning for urinary tract infection (UTI) prophylaxis was discontinued 12/13/22. A Physician Order dated 08/30/22 directed to complete post-void residual (PVR) for voiding diary. One time only for monitoring for one day. Document PVR on voiding diary and incontinence assessment. A Physician Order dated 008/31/22 directed catheter care and output every shift related to retention of urine was discontinued 09/16/22. R32's EMR lacked orders for the catheter placement during this time frame. The Health Status Note dated 09/01/22 at 08:18 PM documented R32 currently had a foley catheter and was concerned that R32 was retaining urine. Upon assessment R32 reported some discomfort when palpated (a technique used in physical examination in which the examiner feels the texture, size, consistency, and location of certain body parts with his/her hands). R32 had medium yellow output with no sediment noted in the leg bag. The Health Status note dated 09/06/22 at 09:55 AM documented R32 was not feeling well that morning. R32 stated she felt dizzy and lightheaded. R32 stated she felt the need to urinate. R32 had a foley catheter in place, with 250 ml in the bag. Sediment was present in tubing. Foley catheter was changed with 16 French (FR) catheter, patent and draining. R32 continued to complain of urge to urinate and low back pain. Pain medication given and R32 to be seen on physician rounds. The Health Status note dated 09/08/22 at 08:30 documented R32 complained of bladder pressure and a pinching feeling, R32 requesting nurse to checking indwelling catheter placement. Foley catheter was patent with minimal straw-colored fluid to bag, peri-care/catheter care completed by staff. Catheter bulb deflated of 10 cubic centimeters (cc) clear fluid. Catheter moved forward two inches and reinflated bulb with 10 cc normal saline. R32 stated her catheter felt better with less pressure, and pinching gone. The Health Status dated 09/09/22 at 01:52 PM documented R32's urinalysis results were received and showed no growth after 48 hours. Physician was notified of lab results and no new orders. The Health Status Note dated 09/12/22 at 01:46 AM documented R32 complained of pain and burning around the catheter insertion site and general discomfort. The Health Status Note dated 09/16/22 at 05:21 AM documented R32 noticed that her catheter was leaking early in the shift. R32's catheter placement was checked as well as the position of the catheter to ensure that it had not kinked off. R32's foley catheter bulb received an additional five to ten milliliters (mL) of sterile water was added to the balloon. The Health Status note dated 09/29/22 at10:22 AM documented R32 inquiring when her foley catheter was last changed. Catheter was changed 09/06/22. R32 wanted to know if her foley catheter would be changed every 30 days, because that was her preference. New order entered from physician's standing orders. The Health status note dated 09/29/22 at 07:41 PM R32's catheter was changed due to leakage, she tolerated procedure well. A Physician Order dated 09/29/22 directed to change foley catheter 16Fr every 30 day(s) for standing order related to retention of urine discontinued 10/04/22). The Health Status note dated 10/04/22 at 02:45 PM documented ER night nurse, R32's foley catheter was clogged with sediment during the night and catheter needed to be changed. The physician was notified by phone, new order to change R32's foley catheter to 18 FR and 30 cc bulb. A Physician Order dated 10/05/22 directed to obtain urinalysis (UA) with culture and sensitivity (C&S) if indicated for dysuria (painful, burning urination usually caused by a bacterial infection or obstruction of the urinary tract) for one day. The Antibiotic Stewardship note dated 10/07/22 at 02:10 PM documented R32 was seen physician assistant for complaint of acute dysuria. Order for UA with C&S if indicated. R32 had a foley catheter in place and did not meet the Loeb criteria (meant to be a minimum set of signs and symptoms which, when met, indicate that the resident likely has an infection and that an antibiotic might be indicated, even if the infection has not been confirmed by diagnostic testing) for this instance. No antibiotics were started at that time. UA obtained by a nurse. A Physician Order dated 10/16/22 directed may change foley catheter 18 FR 30 cc balloon as needed related to retention of urine. A Physician Order dated 10/16/22 directed may flush Foley catheter with 60 cc sterile saline as needed for irrigation. A Physician Order dated11/03/22 directed may change foley catheter 18 FR 30 cc balloon every 30 days per standing order related to retention of urine. The Health Status note dated 11/11/22 at 02:06 PM documented C&S results faxed to physician. A Physician Order dated 11/13/22 Augmentin ablet 875-125 mg (antibiotic used to treat bacterial infection) give one tablet by mouth two times a day for urinary tract infection (UTI) for seven days. The Health Status note dated 11/13/22 at 06:24 AM documented R32 reported foley catheter was leaking, nursing was unable to flush catheter and foley catheter was replaced. R32 tolerated procedure well. The Health Status noted dated 11/29/22 at 08:42 PM documented R32 was seen by physician an order for UA with C&S for proof of cure. Physician order did not meet LOEB criteria. A Physician Order dated 12/02/22 directed cefpodoxime proxetil tablet (antibiotic used to treat bacterial infection) 200mg give one tablet by mouth two times a day for urinary infection for seven days (discontinued 12/05/22). A Physician Order dated 12/05/22 ciprofloxacin HCl tablet (antibiotic used to treat bacterial infection 500mg give one tablet by mouth two times a day for UTI for 10 Days. A Physician Order dated 12/15/22 directed amoxicillin capsule (antibiotic) 250mg give one capsule 250mg by mouth in the morning for UTI prophylaxis. A Physician Order dated 12/19/22 directed monitor foley output every shift, related to retention of urine. Dayshift: Notify provider if output less than 200ml in 12 hours Evening shift: Notify provider if output less than 200ml in 12 hours Night shift: Notify provider if output less than 200ml in 12 hours. The Health Status note dated 01/10/23 at 04:14 PM documented R32 was seen by the physician, order for UA with C&S for proof of cure. The Health Status Note dated 01/22/23 at 01:35 PM documented R32 foley catheter was emptied and 300 mL output with cloudy yellow urine. On 02/02/23 at 10:08 AM R32 sat in a wheelchair next to the bed. R32 wore non-skid socks, R32 had a bed cradle on the foot of the bed which also had a low air loss mattress. R32 had a leg drainage bag on, it contained light amber urine. On 02/02/23 at 01:40 PM Certified Medication Aide (CMA) R stated the nurses provided catheter care and the nurse aides emptied the urine from the drainage bag. CMA R stated the nurse aides changed to dependent drainage bag to the leg drainage bag when R32 got dressed for the day. On 02/02/23 at 02:16 PM Licensed Nurse (LN) I stated anyone could provide catheter care for R32. LN I stated R32 has several UTI's. LN I stated the certified nurse aides change the catheter bag and the LN's change the catheter every 30 days. On 02/02/23 at 03:37 PM Administrative Nurse D stated catheter care should be provided every shift. Administrative Nurse D stated was not sure if a discussion for risk verse benefit had been discussed for R32's catheter and appropriate diagnosis for the use of the catheter. The facility's Foley Catheter Care policy dated 03/31/17 documented catheter care would be provided every shift and when there was a possibility of fecal incontinence. The purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. The facility failed to ensure R32 had an appropriate indication for the ongoing use of an indwelling catheter with no attempts to discontinue. The facility further failed to ensure appropriate foley care orders were in place to direct nursing staff on foley catheter care for R32, who had catheter related discomfort, and multiple UTI with an indwelling urinary catheter. This placed the resident at increased risk for catheter related complications.

The facility reported a census of 56 residents. The sample included 14 residents with 14 reviewed for nurse competency related assessment accuracy. Based on observation, record review, and interviews, the facility failed to ensure staff possessed the skills and knowledge necessary to ensure accuracy of fall assessments for Resident(s) (R) 41 and R44. This deficient practice placed both residents at risk for preventable falls and injuries due to unidentified risk factors. Findings Included: -The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of unsteadiness on feet, macular degeneration (progressive deterioration of the retina), abnormalities of gait and mobility, vertebral fracture of lumbar region (broken bone of the spinal region), and dorsalgia (back pain). R41's admission Minimum Data Set (MDS) dated 11/21/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated that she required extensive assistance from one staff member for bed mobility, transfers, dressing, toileting, and bathing, The MDS noted she required supervision and set-up assistance for personal hygiene. The MDS noted she used a walker and wheelchair for mobility. The MDS noted no falls since admission. R41's Activities of Daily Living (ADLs) Care Area Assessment (CAA) 11/28/22 noted that staff will assist resident with ADLs as needed and her needs will be care planned. R41's Falls CAA 11/28/22 indicated she had a history of falls, used assistive devices, and was assessed to be a high fall risk. The CAA noted the R41 had two falls before her admission in June. A review of R41's Care Plan for Falls initiated 11/15/22 indicated that she was at risk for falls related to impaired balance, mobility, and weakness. The plan instructed staff to encourage R41 to use her call light for assistance and work with therapy services (11/15/22). On 01/25/22 a note was added to R41's Fall care plan indicating that her walker had been removed from service and taken to maintenance to services the brakes. The update noted an armchair was added at the sink for personal cares and instructing staff to frequently check on her. A review of R41's Care Plan for ADLs initiated 11/15/22 indicated that she required one to one moderate assistance with ambulation, bathing, dressing, grooming, transfers, and toileting (11/15/22). The plan indicated the she transfers with gait belt (11/15/22). A review of R41's Fall Assessment completed by Licensed Nurse (LN) H on 11/15/22 revealed a score of 14 indicating she was a high risk for falls. A review of R41's Fall Assessment completed byLN H on 11/28/22 revealed a score of one indicating she was a low fall risk. The re-assessment did not account for R41's impaired mobility, instability while turning, previous fall history, medications, and diagnosis. On 02/02/23 at 02:20PM LN H stated that all resident received a fall assessment upon admission and then another assessment two weeks later. She stated that assessments should be completed every year, quarter, and after a change or fall occurs. She stated that fall assessments include reviewing a resident's previous falls, diagnoses, level of assistance, and recent changes in cognition. She stated that she does not look at the resident's previous assessments, she just reviewed their current status as the assessment was being completed. She stated that if a significant change occurred in the resident risk assessment, she would notify the interdisciplinary team (IDT). On 02/02/23 at 02:50PM Administrative Nurse E stated that the facility's MDS assessment uses the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated that inaccurate data could completely change the care a resident receives. She stated that she was unaware why R41's fall risk changed from high to low within the time assessed but would look into it. A review of the facility's Fall Prevention policy revised 09/2018 indicated that all residents will be assessed for fall risk upon admission, one week after admission, and upon falling or changes in cognition. The policy noted that the assessment will alert the facility of the level prevention needed based on the resident's fall score. The policy indicated that residents with a high-risk score will have an immediate care plan initiated with interventions to prevent accidents or falls. The policy noted the fall score will also indicate the level of assistance needed for care of the resident. The facility failed ensure that nursing staff completed an accurate Fall Assessment for R41. This deficient practice placed both residents at risk for preventable falls and injuries. -The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement), acute kidney failure, and history of total knee replacement surgery. R44's admission Minimum Data Set (MDS) dated 11/28/22 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS indicated that he required limited assistance from one staff for transfers, bed mobility, dressing, personal hygiene, toileting, and bathing. The MDs indicated no falls. A review of R44's Activates of Daily Living (ADLs) Care Area Assessment completed 11/07/22 noted he had been hospitalized due to progressive weakness and being unable to get out of his recliner. The CAA noted that staff would assist him as needed. R44's Falls CAA completed 11/07/22 noted that he was a fall risk related to his urinary incontinence, use of assistive devices, and cognitive impairment. The CAA noted his Fall Assessment score was 18 indicating a high fall risk. A review of R44's Care Plan for Falls initiated 10/27/22 instructed staff to encourage him to use his call light. On 11/14/22 a new intervention was added to R44's plan for staff to provide instructions and education to R44 related to safe measures but did not state what those measures were. A review of R44's Care Plan for ADLs initiated 10/27/22 indicated that he required one to one moderate assist for transfers, ambulation, dressing, grooming, toileting, and bathing. The plan noted the he required a gait belt with all transfers. A review of R44's Fall Assessment completed on 10/28/22 revealed a score of 18 indicating he was a high risk for falls. A review of R44's Fall Assessment completed on 11/09/22 revealed a score of 22 indicating he was a high risk for falls. A review of R44's Fall Assessment completed on 11/15/22 revealed a score of eight indicating a low to moderate risk for falls. The assessment did not accurately account for R44's safety awareness and judgement, incontinence, unstable gait, fall history, and medications which caused his fall risk to lower. On 02/02/23 t 02:20PM Licensed Nurse (LN) H stated that all resident received a fall assessment upon admission and then another assessment two weeks later. She stated that assessments should be completed every year, quarter, and after a change or fall occurs. She stated that fall assessments include reviewing a resident's previous falls, diagnoses, level of assistance, and recent changes in cognition. She stated that she does not look at the resident's previous assessments, she just reviewed their current status as the assessment was being completed. She stated that if a significant change occurred in the resident risk assessment, she would notify the interdisciplinary team (IDT). On 02/02/23 at 02:50PM Administrative Nurse E stated that the facility's MDS assessment uses the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated that inaccurate data could completely change the care a resident receives. She stated that she was unaware why R44's fall risk changed from high to low within the time assessed but would look into it. A review of the facility's Fall Prevention policy revised 09/2018 indicated that all residents will be assessed for fall risk upon admission, one week after admission, and upon falling or changes in cognition. The policy noted that the assessment will alert the facility of the level prevention needed based on the resident's fall score. The policy indicated that residents with a high-risk score will have an immediate care plan initiated with interventions to prevent accidents or falls. The policy noted the fall score will also indicate the level of assistance needed for care of the resident. The facility failed ensure that nursing staff completed an accurate Fall Assessment for R44. This deficient practice placed both residents at risk for preventable falls and injuries.

The facility identified a census of 56 residents. The sample included 14 residents with five reviewed for unnecessary medications. Based on observation, interviews, and record review the facility failed ensure Resident (R) 29's remained free from antipsychotic (medication sued to treat major mental disorders) use when they failed to attempt a gradual dose reduction (GDR) for R29's antipsychotic she received for an inappropriate indication and failed to provide education and obtain informed consent regarding risk versus benefit for continued use of the antipsychotic. The facility further failed to monitor for side effects related to antipsychotic and antidepressant use. This placed R29 at increased risk for side effects and complications related to antipsychotic medication use. Findings included: - R29's Electronic Medical Record (EMR) recorded diagnoses of cerebral infarction (stroke- occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia and hemiparesis following cerebral infarction (weakness or the inability to move on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (persistent feeling of sadness). R29's Quarterly MDS dated 12/05/22 recorded R29 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R29 required extensive assistance of one to two staff for most activities of daily living (ADL), extensive assistance of two staff for bed mobility, but was totally dependent on two staff for toileting and transfers. The MDS recorded R29 had no behaviors. The MDS recorded R29 was frequently incontinent of urine but was continent of bowel. The MDS documented R29 had trialed a toileting program since admission but was not currently on a toileting program. R29 had two or more falls since the previous assessment, one with injury. The MDS documented r29 received an antipsychotic medication (medication used to treat major mental disorders), an antidepressant (medication used to treat depression) and a diuretic (medication which promotes the formation and excretion of urine) all seven of the looks back days. The MDS documented a gradual dose had been attempted on 11/14/22. The Care Plan dated documented R29 took medications which had black box warning (the strongest warning a medication can have issued by the Food and Drug Administration [FDA]). The plan documented since R29 took medications with a black box warning, staff should monitor her for the significant reactions that could occur and notify her physician immediately if any should occur. The care plan lacked mention of the significant reactions to monitor for, side effects related to the antipsychotic and antidepressant use and lacked the targeted behaviors monitored related to the medication use. R29's EMR, under the orders tab recorded the following orders: Seroquel (antipsychotic) tablet 25 milligrams (mg), give one tablet by mouth at bedtime related to major depressive disorder dated 08/31/22. Trazodone (antidepressant) 50 mg, give one tablet by mouth at bedtime related to major depressive disorder dated 08/31/22. Effexor XR (antidepressant) capsule extended release 24-hour 75 mg, give one capsule orally in the morning related to major depressive disorder, dated 12/16/22. Monitor for behaviors related to Seroquel and trazodone use. The target behavior listed was yelling out. The order, dated 10/10/22, directed staff to document the number of behaviors noted during the shift, the (non-pharmacological) intervention that was tried and the outcome of the intervention. The clinical record lacked evidence staff monitored for side effects. A Note to Attending Physician by the Consultant Pharmacist (CP), dated 09/05/22 recorded the resident was taking Seroquel 25 mg daily with a diagnosis of depression. Per Center for Medicare and Medicaid Services (CMS) guidelines, only the FDA approved indications of Tourette 's, Huntington's, or Schizophrenia was allowed for the continued use of antipsychotics in patients with dementia due to the increased rate of mortality and lack of efficacy when used in patients with dementia-related psychosis. Please consider a trial reduction of Seroquel to reduce inappropriate antipsychotic use; if continued use of Seroquel at current dose is warranted, please provide a risk versus benefit statement below. Thank you On 09/14/22 Consultant HH agreed with the recommendation and ordered to discontinue the Seroquel. The note had a handwritten annotation at the bottom family declined dated 09/14/22. A Pharmacy note dated 09/14/22 documented a pharmacy recommendation was received from Consultant HH regarding a GDR of Seroquel with orders to discontinue the Seroquel. The note recorded R29's family declined any changes to this medication at that time. No changes were made. The note lacked evidence the physician was notified. Review of R29's clinical record lacked evidence the facility provided education to R29 and/or her representative regarding the risks of continued use of the antipsychotic without an appropriate indication and lacked evidence of informed consent. A Note to Attending Physician by the Consultant Pharmacist (CP), dated 11/05/22 recorded the resident was taking Seroquel 25 mg daily with a diagnosis of depression. Per CMS guidelines, only the FDA approved indications of Tourette 's, Huntington's, or Schizophrenia was allowed for the continued use of antipsychotics in patients with dementia due to the increased rate of mortality and lack of efficacy when used in patients with dementia-related psychosis. Please consider a trial reduction to Seroquel 12.5mg daily to reduce inappropriate antipsychotic use; if continued use of Seroquel at current dose is warranted, please provide a risk versus benefit statement below. Thank you On 11/14/22 Consultant HH agreed with the recommendation and ordered to discontinue the Seroquel. The note had a handwritten annotation at the bottom family refused dated 11/16/22. A Pharmacy note dated 11/16/22 documented the pharmacy recommendation received from Consultant HH ordered to discontinue the medication however R29's family felt that R29 was better on the medication and did not want it discontinued at that time. No changes were made to Seroquel order per family request. The note lacked evidence the physician was notified. Review of R29's clinical record lacked evidence the facility provided education to R29 and/or her representative regarding the risks of continued use of the antipsychotic without an appropriate indication and lacked evidence of informed consent. On 02/01/23 at 09:15 AM R29 sat in a wheelchair, next to her bed with a bedside table in front of R29 and a soft touch call light on the bedside table. On 02/02/23 at 01:55 PM Licensed Nurse (LN) G stated he had never been asked to educate or explain the risk verse benefit of continued use of any antipsychotic medication to a family member or resident. LN G stated the physician would discuss that with the resident or family member. On 02/02/23 at 03:37 PM Administrative Nurse D stated no education was provided to R29's family regarding the risk verse benefit of continued use of psychotropic medication with out trying a gradual dose reduction. The facility's Psychotropic Medication Monitoring policy dated 01/09/23 documented Primary care physician responsibilities include Documented discussions with the resident and/or responsible party regarding the risk versus benefit of the use of these medications included in the discussion. The facility failed ensure R29 remained free from antipsychotic use when they failed to attempt a GDR for R29's antipsychotic she received for an inappropriate indication and failed to provide education and obtain informed consent regarding risk versus benefit for continued use of the antipsychotic. The facility further failed to monitor for side effects related to antipsychotic and antidepressant use. This placed R29 at increased risk for side effects and complications related to antipsychotic and psychotropic medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 56 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure the residents' plans of care were revised to include necessary information and interventions related to the residents care needs for Resident (R) 19, R41, R44, R29, R32 and R40. This deficient practice placed these residents at risk for uncommunicated care needs and inadequate care. Findings Included: -The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (a condition with low heart output and the body becomes congested with fluid), macular degeneration (progressive deterioration of the retina), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). R19's Quarterly Minimum Data Set (MDS) dated 11/12/22 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS noted she required limited assistance for transfers, toileting, bed mobility, personal hygiene, and bathing. R19's Fall Care Area Assessment (CAA) dated 08/12/22 noted she had a potential for falls use to use of assistive device, incontinence, psychotropic medication (medication capable of affecting the mind, emotions, and behaviors), and cognitive impairment. R19's Activities of Daily Living (ADLs) CAA dated 08/12/22 indicated that she needed assistance with some ADLs and incontinence. The CAA noted she had history of hallucinations (seeing or hearing things that are not real). A review of R19's Care Plan for Falls initiated 08/01/19 indicated that she would have a fall assessment completed upon admission and two weeks after admission [DATE]). The plan instructed staff to encourage R19 to use her call light (08/01/19) and remind her to wear her rubber-soled house shoes or tennis shoes ()08/01/19). The care plan lacked direction on the use of an electric lift recliner. A review of R19's Care Plan for ADLs initiated 08/01/19 indicated that R19 may transfer independent with her walker (08/01/19) , dress independently (08/01/19), toilets self but may require cueing (08/01/19), and preferred to get up between 10:00AM and 11:AM (02/01/22). The care plan lacked direction regarding the use of the electric lift chair. The care plan lacked updated interventions related to R19's recent falls on 09/01/22, 09/10/22, and 10/14/22. A review of R19's EMR revealed a Health Status note on 09/01/22 revealed that R19 was found yelling, sitting on the floor of her room in front of her recliner. The note indicated that R19 was unable to explain to staff what she was doing before the fall. The note indicated that R19 had no socks or shoes on at the time of the fall. A review of R19's EMR revealed an Incident note on 09/10/22 indicated that R19's recliner tipped upward resulting in her sliding onto the floor. The note indicated R19 could not figure out the recliner buttons and slid out of the chair onto the floor. The note indicated that R19 had no injuries, and the resident representative was notified. The note indicated that the representative informed staff that she knew how to use the chair lift recliner. The note included an intervention to provide resident education on recliner use and encourage R19 to use the call light. A review of R19's EMR on 02/02/23 revealed no documentation of education or safety risk assessment for the use of the electric lift- reclining chair. A review of R19's EMR revealed an Incident note dated 10/14/22 indicated that R19 was found on her floor next to her bed in a pool of urine due to an incontinence episode. The note indicated the R19 tripped over a fan cord attempting to go to the restroom. The note listed that staff should ensure her floor is free from clutter, educate R19 to call for assistance, and remind her to wear socks and shoes when walking. R19's EMR lacked evidence staff implemented personalized interventions to prevent future falls. On 01/31/23 at 10:49AM R19 reported that she has fallen out of her chair a few times but could not remember if she received education on how to use the remote. She stated that the facility did label the remote after she had slid out of the chair onto the floor. R19 was in her bed reading a book. R19's lift recliner chair sat opposite of her bed. The chair had the brown (slick) covering still on it. On 02/02/23 at 01:36PM in an interview with Certified Medication Aid (CMA) R, she stated that direct staff have access to review the residents care plan. She stated that the resident should be monitored and assisted based on the level of care listed within the care plan. She stated that direct care can tell the nurse if a change is needed for care, or the resident does not maintain the level of care listed in the care plan. She stated that all residents should have education provided on how to use the recliner/lift chairs but not sure where it would be documented. On 02/02/23 at 02:20PM in an interview with Licensed Nurse I, she stated that residents should not use the electric chairs until given education but not sure where it was documented. She stated that all staff have access to the care plans and can view it when needed. She stated that he was familiar with some of the residents sliding out of their chairs and stated that the facility would educate them on how to use the remotes. She stated that R19 is more independent and sometimes does not ask for help before transferring or walking. On 02/02/23 at 02:50PM Administrative Nurse E stated that the facility's MDS assessment use the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated that inaccurate data could completely change the care a resident receives. She stated that the interdisciplinary teams (IDT) will meet to review and discuss each resident's care plans weekly and review any changes or updates. She stated the nurses can make suggestions to the IDT for changes in the care. A review of the facility's Directed Care Plans policy (undated) noted that the resident's individualized care plan will be created by the interdisciplinary team based upon the resident's needs, assessments, treatments, and services provided. The policy noted that it is the responsibility of all staff to review the resident's care plans and follow the care, treatment and services outlined. The facility failed to revise the care pan with updated interventions related to R19's falls. This deficient practice placed R19 at risk for preventable falls and injuries. -The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of unsteadiness on feet, macular degeneration (progressive deterioration of the retina), abnormalities of gait and mobility, vertebral fracture of lumbar region (broken bone of the spinal region), and dorsalgia (back pain). R41's admission Minimum Data Set (MDS) dated 11/21/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated that she required extensive assistance from one staff member for bed mobility, transfers, dressing, toileting, and bathing, The MDS noted she required supervision and set-up assistance for personal hygiene. The MDS noted she used a walker and wheelchair for mobility. The MDS noted no falls since admission. R41's Activities of Daily Living (ADLs) Care Area Assessment (CAA) 11/28/22 noted that staff will assist resident with ADLs as needed and her needs will be care planned. R41's Falls CAA 11/28/22 indicated she had a history of falls, used assistive devices, and was assessed to be a fall risk. The CAA noted the R41 had two falls before her admission in June. A review of R41's Care Plan for Falls initiated 11/15/22 indicated that she was at risk for falls related to impaired balance, mobility, and weakness. The plan instructed staff to encourage R41 to use her call light for assistance and work with therapy services (11/15/22). On 01/25/22 a note was added to R41's Fall care plan indicating that her walker had been removed from service and taken to maintenance to services the brakes. The update noted an armchair was added at the sink for personal cares and instructing staff to frequently check on her. The care plan lacked intervention documentation for R41's fall on 01/14/23. A review of R41's Care Plan for ADLs initiated 11/15/22 indicated that she required one to one moderate assistance with ambulation, bathing, dressing, grooming, transfers, and toileting (11/15/22). The plan indicated she transfers with gait belt (11/15/22). A review of R41's Fall Assessment completed by Licensed Nurse (LN) H on 11/15/22 revealed a score of 14 indicating she was a high risk for falls. A review of R41's Fall Assessment completed by Licensed Nurse (LN) H on 11/28/22 revealed a score of one indicating she was a low fall risk. The re-assessment did not account for R41's impaired mobility, instability while turning, previous fall history, medications, and diagnosis. A review of R41's EMR revealed a Health Status note on 01/14/23 indicated that staff found R41 lying on the floor in her bathroom. The note indicated that R41 lost her balance and fell sideways on her left side. The note stated that even though the resident had a high BIMS of 15 she had become more forgetful the last couple of weeks. A review of R41's EMR under Incident note on 01/25/23 revealed that R41 fell while completing personal hygiene at the sink in her room. The note indicated that R41 was assisted to sit in her rolling walker and left alone while brushing her teeth. R41 reported to staff that she attempted to scoot her walker backwards and fell on her head. The note indicated that R41 had a two-centimeter (cm) laceration (wound to the skin) on the back of her head. R41 was transferred to an acute care facility and required surgical staples to close the wound. The note indicated that she also had a 2cm x1.5cm hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the back of her head. On 02/02/23 at 01:36PM Certified Medication Aid (CMA) R noted that R41 should never be left alone during cares because she was a high fall risk. She stated that residents that are on one-to-one assist require a staff to be with them at all times during the tasks. CMA R stated that R41 forgets to call for help sometimes and will try and do things for herself. She stated that R41's care plan required her to be assisted with all tasks due to her risk of falls. On 02/02/23 at 02:50PM Administrative Nurse E stated that the facility's MDS assessment use the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated that inaccurate data could completely change the care a resident receives. She stated that the interdisciplinary teams (IDT) will meet to review and discuss each resident's care plans weekly and review any changes or updates. She stated the nurses can make suggestions to the IDT for changes in the care. On 02/02/2023 at 10:00AM an inspection of R41's room was completed. The room was clean and free of clutter. A wheelchair was stationed next to her sink, and a grab bar was installed in her toilet area. R41 stated that she did fall . A review of the facility's Directed Care Plans policy (undated) noted that the resident's individualized care plan will be created by the interdisciplinary team based upon the resident's needs, assessments, treatments, and services provided. The policy noted that it is the responsibility of all staff to review the resident's care plans and follow the care, treatment and services outlined. The facility failed to revise the care pan with updated interventions related to R41's fall on 01/14/23. This deficient practice placed R41 at risk for preventable falls and injuries. -The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), arthritis (inflammation of a joint characterized by pain, swelling, heat, redness, and limitation of movement), acute kidney failure, and history of total knee replacement surgery. R44's admission Minimum Data Set (MDS) dated 11/28/22 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS indicated that he required limited assistance from one staff for transfers, bed mobility, dressing, personal hygiene, toileting, and bathing. The MDs indicated no falls. A review of R44's Activates of Daily Living (ADLs) Care Area Assessment completed 11/07/22 noted he had been hospitalized due to progressive weakness and being unable to get out of his recliner. The CAA noted that staff would assist him as needed. R44's Falls CAA completed 11/07/22 noted that he was a fall risk related to his urinary incontinence, use of assistive devices, and cognitive impairment. The CAA noted his Fall Assessment score was 18 indicating a high fall risk. A review of R44's Care Plan for Falls initiated 10/27/22 instructed staff to encourage him to use his call light. On 11/14/22 a new intervention was added to R44's plan for staff to provide instructions and education to R44 related to safe measures but did not state what those measures were. A review of R44's Care Plan for ADLs initiated 10/27/22 indicated that he required one to one moderate assist for transfers, ambulation, dressing, grooming, toileting, and bathing. The plan noted the he required a gait belt with all transfers. A review of R44's Fall Assessment completed on 10/28/22 revealed a score of 18 indicating he was a high risk for falls. A review of R44's Fall Assessment completed on 11/09/22 revealed a score of 22 indicating he was a high risk for falls. A review of R44's Fall Assessment completed on 11/15/22 revealed a score of eight indicating a low to moderate risk for falls. The assessment did not accurately account for R44's safety awareness and judgement, incontinence, unstable gait, fall history, and medications which caused his fall risk to lower. A review of R44's EMR revealed a Health Status note dated 11/4/22 that indicated R44 was found by staff laying on his stomach with his right arm underneath him on the floor. The note revealed his head was directly underneath the air conditioning unit. The note revealed R44 did not have socks or shoes on. The note revealed R44 had an abrasion to the left side of his fore head and one on his knee. The note revealed that R44 was trying to turn down the room's heater. R44's EMR lacked evidence interventions were implemented as a result of the fall to prevent future falls. R44's EMR revealed a Health Status note on 11/08/22 indicated that R44 was found by staff sitting on the floor outside of his bathroom with his pants unbuttoned. R44's walker was found inside his bathroom. He was not wearing slippers or non-skid socks. The note revealed that R44 was not sure what he was doing at the time of his fall. R44's EMR lacked evidence a root cause analysis was completed, or interventions implemented to prevent future falls. On 02/02/23 at 01:36PM Certified Medication Aid (CMA) R noted that direct staff have access to review the residents care plan. She stated that the resident should be monitored and assisted based on the level of care listed within the care plan. She stated that direct care can tell the nurse if a change is needed for care or the resident does not maintain the level of care listed in the care plan. She stated that during each fall episode the direct care staff will notify the nurse immediately. She stated that staff will stay with the resident until help arrives and then assist the nurse. On 02/02/23 at 02:50PM Administrative Nurse E stated that the facility's MDS assessment use the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated that inaccurate data could completely change the care a resident receives. She stated that the interdisciplinary teams (IDT) will meet to review and discuss each residents care plans weekly and review any changes or updates. She stated the nurses can make suggestions to the IDT for changes in the care. A review of the facility's Directed Care Plans policy (undated) noted that the resident's individualized care plan will be created by the interdisciplinary team based upon the resident's needs, assessments, treatments, and services provided. The policy noted that it is the responsibility of all staff to review the resident's care plans and follow the care, treatment and services outlined. The facility failed to revise the care pan with updated interventions related to R44's fall on 01/14/23. This deficient practice placed R44 at risk for preventable falls and injuries. - R29's Electronic Medical Record (EMR) recorded diagnoses of cerebral infarction (stroke- occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia and hemiparesis following cerebral infarction (weakness or the inability to move on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). R29's admission Minimum Data Set (MDS) dated 09/04/22 Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. She had verbal behaviors directed towards others for one to three days of the look back period. Significantly interfered with her participation in activities and significantly intruded on the privacy or activity of others and disrupted cares and the living environment. The Falls Care Area Assessment dated 09/11/22 recorded R29 had potential for falls due to a history of falls. Use of psychotropic (alters mood or thought) medication and stroke issues. She had cognitive impairment. Her fall assessment score was 13. The CAA documented R29 did not ambulate and required two staff assist with transfers with a gait belt and she sued a wheelchair for mobility. R29's Quarterly MDS dated 12/05/22 recorded R29 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R29 required extensive assistance of one to two staff for most activities of daily living (ADL), extensive assistance of two staff for bed mobility, but was totally dependent on two staff for toileting and transfers. The MDS recorded R29 had no behaviors. The MDS recorded R29 was frequently incontinent of urine but was continent of bowel. The MDS documented R29 had trialed a toileting program since admission but was not currently on a toileting program. R29 had two or more falls since the previous assessment, one with injury. The MDS documented r29 received an antipsychotic medication (medication used to treat major mental disorders), an antidepressant (medication used to treat depression) and a diuretic (medication which promotes the formation and excretion of urine) all seven of the looks back days. The MDS documented a gradual dose had been attempted on 11/14/22. The Care Plan documented R29 had safety/fall risk due to impaired mobility. The plan recorded interventions dated 08/29/22 which directed staff to assure lighting was appropriate, encourage family participation, encourage resident to sue the call light for staff assistance, an update was added on 11/08/22 which directed staff to place a fall mat at the bedside and recorded the resident would work with therapy to gain strength and balance. An update on 12/29/22 directed staff to place a body pillow on R29's right side when she was in bed. The Care Plan dated 08/29/22 recorded R29 required extensive assistance with ADL. The plan dated 08/2922 directed staff R29 required two staff assistances for transfers and directed staff to encourage R29 to stand up tall and look up and to allow R29 time to do it. An intervention dated 08/29/22 directed staff that R29 needed to sue the big bathroom for toileting. It instructed staff she required assistance from two staff for the transfer and to cue her to stand tall and look up and allow her time to do that. The Care Plan dated 08/29/22 recorded R29 had late effects from a stroke and an intervention dated 08/29/22 directed she required staff assistance with toileting but was left blank on the amount of assistance or staff. The plan further directed staff R29 had diabetes (disease that affects the body's ability to use sugar and results in high blood sugar levels) and directed staff to monitor for symptoms which included increased urination. The care plan lacked further direction related to incontinence, or toileting such as frequency or resident specific toileting preferences/schedules. The admission Continence Assessment dated 08/29/22 which was unlocked and remained in progress at the time of the survey recorded R29 did not have an indwelling catheter, had trouble holding her urine and sometimes used pads to protect her clothing due to urine leakage. The assessment recorded the resident had trouble controlling her urine prior to admission for over a year and had urine leakage all the time. The assessment recorded R29 had trouble controlling her urine related to it coming on so fast she could not get to the toilet, but she could tell when she had to urinate. The assessment further recorded she needed assistance in the bathroom with her clothing, getting on and off the toilet, and performing peri cares. The assessment recorded she received antipsychotic/antidepressant medication and had diabetes. The results section which indicated if a post void residual result, a three-day voiding diary completed, physician review of the assessment results, a toileting plan developed and the care plan updated to reflect toileting plan was left blank. The quarterly Continence Assessment dated 12/01/22 but unlocked and in progress at the time of the survey recorded R29 did not have an indwelling catheter, had trouble holding her urine and sometimes used pads to protect her clothing due to urine leakage. The assessment recorded the resident had trouble controlling her urine prior to admission for over a year and had urine leakage all the time. The assessment recorded R29 had trouble controlling her urine due to difficulty managing in the bathroom causing accidents in the bathroom and she could sometimes tell when she had to urinate. The assessment further recorded she needed assistance in the bathroom with her clothing, getting on and off the toilet, and performing peri cares. The assessment recorded she received antipsychotic/antidepressant medication, diuretics, and had diabetes. The results section which indicated if a post void residual result, a three-day voiding diary completed, physician review of the assessment results, a toileting plan developed and the care plan updated to reflect toileting plan was left blank. R29's clinical record lacked evidence of further assessment related to her incontinence and/or development of a toileting program or personalized toileting schedule. An Incident Note dated 11/19/22 at 11:06 AM recorded an investigation was performed regarding the resident fell in her room. The Certified Nurse Aide (CNA) found R29 on the floor. The Licensed Nurse (PN) observed R29 laying in the prone (on her stomach) position on the floor with R29's head towards the doorway. R29 had new abrasions to her forehead and nose and a hematoma (collection of blood under the skin due to trauma) to the apex of her nose. The root cause was recorded as the resident was trying to take herself to the bathroom. The note recorded the intervention was a reminder for nurses to educate and monitor staff, and re-educate if needed, that R29 needed toileted at least every two hours to assist in preventing falls. It further documented the care plan was appropriate and to continue with current plan and the Kardex (tool for direct care staff which directed resident needs) was updated as well for CNA staff reminder to toilet resident every two hours to also help with fall prevention. An Incident Note dated 12/29/22 at 12:47 PM recorded an investigation was performed regarding the resident fell in her room on 12/25/22. The LN entered the room and observed R29 on the floor next to her bed. R29 laid on her stomach with her head turned and her right cheek rested on the floor. R29 was incontinent or urine. The note recorded the root cause was the resident needed to go to the bathroom. The note documented the intervention was to be sure the body pillow in place on the resident's right side and encourage staff to take R29 to the bathroom when she was tearful to be sure it was not an unmet need. On 02/01/23 at 09:15 AM R29 sat in a wheelchair, next to her bed with a bedside table in front of R29 and a soft touch call light on the bedside table. On 02/02/23 at 01:36 PM in an interview with Certified Medication Aid (CMA) R, she stated that direct staff have access to review the residents care plan. She stated that the resident should be monitored and assisted based on the level of care listed within the care plan. She stated that direct care can tell the nurse if a change is needed for care, or the resident does not maintain the level of care listed in the care plan. On 02/02/23 at 01:55 PM in an interview with Licensed Nurse (LN) G stated he was not sure if R29's Care Plan addressed why R29 cried and how the staff would know what care R29 needed. On 02/02/23 at 02:20 PM in an interview with Licensed Nurse I, she stated that all staff have access to the care plans and can view it when needed. On 02/02/23 at 02:50 PM Administrative Nurse E stated that the facility's MDS assessment use the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated that inaccurate data could completely change the care a resident receives. She stated that the interdisciplinary teams (IDT) will meet to review and discuss each resident's care plans weekly and review any changes or updates. She stated the nurses can make suggestions to the IDT for changes in the care. CMA R stated she was not sure if R29's Care Plan directed staff on how to provide care whenR29 was crying. A review of the facility's Directed Care Plans policy (undated) noted that the resident's individualized care plan will be created by the interdisciplinary team based upon the resident's needs, assessments, treatments, and services provided. The policy noted that it is the responsibility of all staff to review the resident's care plans and follow the care, treatment and services outlined. The facility failed to revise R29's comprehensive Care Plan to include person-centered interventions which directed staff on the necessary care and services required by R29 to support his highest practicable level for bladder continence and psychosocial well-being. - R32's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), need for assistance with personal care, and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R32 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R32 was at risk of pressure ulcers and had one unhealed pressure ulcer. The MDS documented R32 had a pressure reducing device in her chair, pressure ulcer care and application of medication/ointments to other then feet. The MDS lacked documentation pressure reducing mattress, turning, or repositioning, or nutritional interventions. The Quarterly MDS dated 12/22/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R32 was dependent on two staff members assistance for ADLs. The MDS documented R32 was at risk for pressure ulcers and documented no unhealed pressure ulcers. R32's Pressure Ulcer Care Area Assessment (CAA) dated 09/28/22 documented R32 had the potential for pressure related to hospice status with declined nutritional intake. The Urinary Incontinence CAA documented R32 had a foley catheter. R32's Care Plan lacked documentation related to pressure ulcer prevention or care. R32's Care Plan lacked any documentation regarding the catheter including care and reason for continued indwelling catheter. The Health Status Note dated 09/01/22 at 08:18 PM documented R32 currently had a foley catheter and was concerned that R32 was retaining urine. Upon assessment R32 reported some discomfort when palpated (a technique used in physical examination in which the examiner feels the texture, size, consistency, and location of certain body parts with his/her hands). R32 had medium yellow output with no sediment noted in the leg bag. The Health Status note dated 09/06/22 at 09:55 AM documented R32 was not feeling well that morning. R32 stated she felt dizzy and lightheaded. R32 stated she felt the need to urinate. R32 had a foley catheter in place, with 250 ml in the bag. Sediment was present in tubing. Foley catheter was changed with 16 French (FR) catheter, patent and draining. R32 continued to complain of urge to urinate and low back pain. Pain medication given and R32 to be seen on physician rounds. The Health Status note dated 09/08/22 at 08:30 documented R32 complained of bladder pressure and a pinching feeling, R32 requesting nurse to checking indwelling catheter placement. Foley catheter was patent with minimal straw-colored fluid to bag, peri-care/catheter care completed by staff. Catheter bulb deflated of 10 cubic centimeters (cc) clear fluid. Catheter moved forward two inches and reinflated bulb with 10 cc normal saline. R32 stated her catheter felt better with less pressure, and pinching gone. A Skin Assessment dated 09/14/22 documented R32's skin was warm, dry, and intact. A Health Status Note dated 09/19/22 at 01:35 PM recorded a discolored area on R32's left inner heel. The note documented facility wound nurse, hospice nurse and physician were notified of area. A Health Status Note dated 09/20/22 at 05:31 PM documented an order was received for Betadine (topical antiseptic used to disinfection of the skin) to a lesion on the left inner heel and directed to avoid pressure to area until resolved for skin. Review of the EMR under Orders tab revealed physician orders dated 09/20/22 apply Betadine to lesion on left inner heel and avoid pressure to the area until resolved every day. Review of the Treatm[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 44. The sample included 13 residents with one resident reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of stay for Resident (R) 43. This deficient practice had the risk for miscommunication of services received during stay in facility and of post discharge care needs. Findings included: - R43 admitted to facility 06/19/21 and discharged on 07/02/21. The Diagnoses tab of R43's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with cares. The admission Minimum Data Set (MDS) dated [DATE], documented R43 had a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. R43 had active discharge planning in place and planned to discharge to community. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/25/21, documented R43 had cognitive impairment. The Discharge Planning Care Plan dated 06/19/21, documented R43 had discharge plans to return to another facility to live on the dementia unit. The Assessments tab of R43's EMR revealed a Discharge Instructions for Care Assessment dated 07/01/21, lacked a recapitulation of stay. A Health Status Note on 07/02/21 at 02:06 PM, in the Notes tab of R43's EMR, documented R43 discharged from the facility at 01:30 PM with her daughter in a personal vehicle and would return to a memory care facility with home health services. R43 received scheduled medications, meals, and a shower prior to discharge. The Note lacked a recapitulation of stay. On 08/18/21 at 01:46 PM, Licensed Nurse (LN) G stated when a resident discharged from facility, a progress note was documented that included how and when the resident left, any services they went home with, if resident understood discharge instructions, any questions that were answered, follow-up appointments, and what belongings were taken with resident. LN G stated a recapitulation of stay did not get completed. On 08/18/21 at 02:23 PM, Administrative Nurse D stated when a resident discharged from facility, the nurses documented a progress note and a discharge summary. The progress note included who the resident discharged with, belongings taken, and if medications were sent with resident or not sent with resident. She stated a recapitulation of stay was not completed. The facility's Providing Clinical Information at Transfer to Another Facility policy, dated 01/20/17, lacked direction on documenting in the medical record, a discharge summary and recapitulation of stay at time of discharge. The facility failed to provide a recapitulation of stay at discharge for R43. This deficient practice had the risk for miscommunication of services received during stay in facility and of post discharge care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 44 residents. The sample included 13 residents; five residents sampled for unnecessary medication review. Based on observations, record reviews, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility the lack of behavior monitoring on two scheduled psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications and on an as needed (PRN) anxiolytic (antianxiety- class of medications that calm and relax people with excessive anxiety [mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear], nervousness, or tension) medication for Resident (R) 39. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use. Findings included: - The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS) dated [DATE], documented R39 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. R39 received antianxiety medication one day and antidepressant medications seven days in the seven-day look back period of the assessment. The Psychotropic Drug Use Care Area Assessment (CAA) dated 08/04/21, documented R39 took antidepressant and antianxiety medications. Remeron (antidepressant- class of medications used to treat mood disorders and relieve symptoms of depression) and Zoloft had black box warnings (BBW- warnings required by the Food and Drug Administration for certain medications that carry serious safety risks) and staff were to monitor for unusual changes in behavior and/or suicidal ideations. The Care Plan dated 07/30/21, documented R39 had a history of depression and anxiety that she took medication for. The Care Plan dated 07/29/21, documented R39 took medications that had black box warnings and directed staff monitored R39 for significant reactions that could occur and notify physician immediately if any occurred. The Orders tab of R39's EMR documented an order with a start date of 07/30/21 and an end date of 08/13/21 for lorazepam (antianxiety) 0.5 milligrams (mg) every six hours as needed for anxiety and terminal agitation for 14 days, an order with a start date of 07/29/21 for sertraline (Zoloft- antidepressant) 100 mg every morning for major depressive disorder, and an order with a start date of 07/29/21 and end date of 08/11/21 for mirtazapine (Remeron- antidepressant) 7.5 mg at bedtime for major depressive disorder. The Orders tab lacked an order for behavior monitoring for lorazepam, sertraline, or mirtazapine. Review of the Treatment Administration Record (TAR) lacked evidence of behavior monitoring for psychotropic medications. The Tasks tab of R39's EMR lacked a task for behavior monitoring for psychotropic medications. Review of the Medication Regimen Review (MRR) for July 2021, dated 08/03/21, lacked evidence the CP identified and reported to facility lack of behavior monitoring for psychotropic medications. On 08/17/21 at 01:49 PM, R39 laid in bed with her eyes closed, she had a visitor sitting at bedside. She appeared comfortable and without signs of distress or discomfort. No behaviors noted. On 08/18/21 at 01:25 PM, Certified Nurse Aide (CNA) M stated if a resident had a history of behaviors then they had behavior monitoring and the aides charted on behaviors in Point of Care (POC- CNA charting system). On 08/18/21 at 01:46 PM, Licensed Nurse (LN) G stated all nursing staff monitored behaviors but mostly the CNAs who reported behaviors to the nurse. The nurse charted behaviors in the TAR and any resident on a psychotropic medication had behavior monitoring. On 08/18/21 at 02:23 PM, Administrative Nurse D stated behavior monitoring was completed every shift by the nurse and documented on the TAR. She stated behavior monitoring was completed on any resident that received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) or antidepressant medications. On 08/19/21 at 08:57 AM, CP GG stated during monthly pharmacy reviews, she checked for behavior monitoring on any resident with psychotropic medications and made recommendations to the facility. CP GG stated the facility only monitored behaviors for residents that received antipsychotic and PRN anxiolytic medications. The facility's Drug Regimen Review policy, dated 11/28/16, directed the licensed pharmacist reviewed the drug regimen for each resident at least monthly and reported any irregularities to the attending provider, director of nursing, and medication director to be acted upon in a timely manner. The facility failed to ensure the CP identified and reported the lack of behavior monitoring to the facility for psychotropic medication use for R39. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease (gradual loss of kidney function), dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, and primary hypertension (high blood pressure). The admission Minimum Data Set (MDS) dated [DATE], documented R39 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/04/21, documented R39 had cognitive impairment. The Care Plan for R39 lacked direction on hypertension management. The Orders tab of R39's EMR documented an order with a start date of 07/29/21 for diltiazem hydrochloride (HCl) extended release (ER) (antihypertensive medication) 180 milligrams (mg) every morning for hypertension, an order with a start date of 07/29/21 for doxazosin mesylate (antihypertensive) 4 mg in the morning for hypertension, and an order with a start date of 07/29/21 for benazepril HCl 40 mg two times a day for hypertension. There were no directions with set parameters for blood pressure and/or heart rate monitoring before antihypertensive medication administration for the above orders, including when to notify the physician. A review of R39's Medication Administration Record (MAR) for July and August 2021 revealed diltiazem had blood pressure and heart rate monitoring with administration but no set parameters for monitoring. Doxazosin and benazepril lacked blood pressure and heart rate monitoring or set parameters. On 08/17/21 at 01:49 PM, R39 laid in bed with her eyes closed, she had a visitor sitting at bedside. She appeared comfortable and without signs of distress or discomfort. On 08/18/21 at 01:36 PM, Certified Medication Aide (CMA) R stated blood pressure medications had set parameters depending on the doctor. If an antihypertensive medication did not have set parameters and the blood pressure or heart rate was higher or lower than the usual for the resident, she held the medication and notified the nurse. On 08/18/21 at 01:46 PM, Licensed Nurse (LN) G stated not all the blood pressure medications had set parameters as it was per provider preference. LN G stated each blood pressure medication should have parameters and if a blood pressure or heart rate was outside set parameters then the medication was held, and the provider was notified. On 08/18/21 at 02:23 PM, Administrative Nurse D stated blood pressure medications should all have parameters, but it was a physician preference. She expected CMA to notify the nurse if there's an abnormal blood pressure and if there's a blood pressure the nurse considered high then the physician was notified. The facility's Nurse Notification to Physician policy, dated 04/16/20, directed the licensed nurse notified the resident's physician when the resident's clinical condition required a physician intervention. The policy lacked direction on antihypertensive medication usage and blood pressure/heart rate monitoring. The facility failed to ensure antihypertensive medications had set parameters for monitoring of blood pressure and/or heart rate for R39. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use. - The Diagnoses tab of R27's Electronic Medical Record (EMR) documented a diagnosis of primary hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R27 had a Brief Interview for Mental Status (BIMS) score of four which indicated severe cognitive impairment. The Quarterly MDS dated 07/10/21, documented R27 had a BIMS score of four which indicated severe cognitive impairment. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 01/07/21, documented R27 had cognitive impairment. The Care Plan dated 06/30/20, directed R27 took medications that had black box warnings (warnings required by the Food and Drug Administration for certain medications that carry serious safety risks) and directed staff to monitor R27 for significant reactions that could occur and notify physician if any reactions occurred. The Care Plan lacked direction on hypertension management. The Orders tab of R27's EMR documented an order with a start date of 08/01/21 for amlodipine besylate (antihypertensive) 5 milligrams (mg) at bedtime for hypertension, an order with a start date of 08/01/21 for diltiazem hydrochloride (HCl) (antihypertensive) 30 mg two times a day for hypertension, an order with a start date of 07/09/20 and a discontinued date of 06/30/21 for metoprolol tartrate (antihypertensive) 12.5 mg twice a day for hypertension with directions to hold if pulse was less than 50 beats per minute and notify the nurse, an order with a start date of 06/30/21 and a discontinued date of 07/09/21 for metoprolol tartrate 25 mg two times a day for hypertension, an order with a start date of 07/09/21 and a discontinued date of 07/12/21 for metoprolol 50 mg every morning and bedtime for hypertension, an order with a start date of 07/12/21 and discontinued date of 08/06/21 for metoprolol tartrate 25 mg two times a day for hypertension, and an order with a start date of 08/06/21 for metoprolol 12.5 mg two times a day for hypertension. Amlodipine, diltiazem, and metoprolol (from 06/30/21 to 08/16/21) lacked set parameters for monitoring and directions for physician notification. A review of R27's Medication Administration Record (MAR) for 05/01/21 to 06/29/21 revealed metoprolol documentation had pulse monitored at administration ; 06/30/21 to 07/08/21 revealed metoprolol documentation had blood pressure and pulse monitored at administration; 07/09/21 to 07/12/21 (morning administration) revealed metoprolol documentation had blood pressure and pulse monitored at administration; and 07/12/21 (bedtime administration) to 08/16/21 revealed metoprolol documentation lacked blood pressure and/or pulse monitoring at administration. Amlodipine documentation had blood pressure and pulse monitored at administration for 08/01/21 to 08/16/21. Diltiazem documentation had blood pressure and pulse monitored at administration for 08/01/21 to 08/16/21. The Notes tab of R27's EMR revealed a Pharmacy Note on 08/17/21 at 01:56 PM that documented a new order was received to discontinue amlodipine due to duplicate therapy with diltiazem. Review of the Orders tab on 08/18/21 revealed amlodipine had not been discontinued as ordered. On 08/17/21 at 04:56 PM, R27 sat in her recliner with her legs elevated. She colored in a coloring book and appeared comfortable. No signs of distress or discomfort were noted. On 08/18/21 at 01:36 PM, Certified Medication Aide (CMA) R stated blood pressure medications had set parameters depending on the doctor. If an antihypertensive medication did not have set parameters and the blood pressure or heart rate was higher or lower than the usual for the resident, she held the medication and notified the nurse. On 08/18/21 at 01:46 PM, Licensed Nurse (LN) G stated not all the blood pressure medications had set parameters as it was per provider preference. LN G stated each blood pressure medication should have parameters and if a blood pressure or heart rate was outside set parameters then the medication was held, and the provider was notified. She stated if there was an order to discontinue a medication, it should have been discontinued as ordered. On 08/18/21 at 02:23 PM, Administrative Nurse D stated blood pressure medications should all have parameters, but it was a physician preference. She expected CMA to notify the nurse if there's an abnormal blood pressure and if there's a blood pressure the nurse considered high then the physician was notified. She stated new orders were changed by the nurse on duty and the night shift nurse reviewed each night for completion. The facility's Nurse Notification to Physician policy, dated 04/16/20, directed the licensed nurse notified the resident's physician when the resident's clinical condition required a physician intervention. The policy lacked direction on antihypertensive medication usage and blood pressure/heart rate monitoring. The facility's Physician Orders for Medications and Treatments policy, dated 04/16/20, directed all medications were administered as ordered by a health care professional authorized by the state to order medications. The facility failed to ensure antihypertensive medications had set parameters for monitoring of blood pressure and/or heart rate for R27 and failed to discontinue an antihypertensive medication as ordered by provider. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use. The facility identified a census of 44 residents. The sample included 13 residents, which five residents were sampled for unnecessary medication review. Based on observation, record review, and interviews, the facility failed to follow the physician order to notify the physician when daily and weekly weights were outside the parameters the facility failed to antihypertensive (class of medication used to treat hypertension (high blood pressure) medication when blood pressures (BP) were outside of physician ordered parameters, and blood glucose (amount of glucose in the blood-glucose is a sugar that comes from the foods we eat, and it's also formed and stored inside the body) that was outside the physician ordered parameters as directed for Resident (R) 17. The facility failed to monitor bowel movements (BM) for possible constipation (difficulty passing stools) for R24. The facility failed to have BP parameters to monitor and administer antihypertensive medications for R39 and R27. The facility failed to follow a physician order to discontinue an antihypertensive medication for R27. Findings included: - R17's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (elevated blood pressure), atrial fibrillation (rapid, irregular heart beat), and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R17 was totally dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R17 received insulin (medication to regulate blood sugar), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) medication, and antibiotic (class of medication used to treat bacterial infections) for seven days during the look back period. R17's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 06/22/21 documented she had a decline in her overall status, escalated blood glucose levels, and she had increased incontinence. She required a Hoyer lift (total body mechanical lift used to transfer residents) and two staff members for transfers. R17's Care Plan dated 01/05/21 documented blood glucose checks before meals and at bedtime. The Care Plan documented R17 received medication with a black box warning (the most serious medication warning put in the labeling of prescription medications by the U.S. Food and Drug Administration when there is reasonable evidence of an association of a serious hazard with the drug), monitor for significant reactions and notify the physician immediately. The Care Plan dated 06/14/21 directed staff to monitor her weights. Review of the EMR under the Orders tab revealed physician orders: Notify physician of blood glucose of fasting blood glucose level greater than (>) 150, all other > 300 dated 01/05/21. glipizide (sulfonylureas- class of medication used to lower blood sugar) tablet five milligrams (mg) by mouth in the morning related to diabetes mellitus dated 06/05/21. Insulin glargine solution 100units/milliliter (ml), inject 18 units subcutaneously (SQ) at bedtime related to diabetes mellitus dated 06/12/21. Humalog (insulin) solution 100unit/ml inject 22 units SQ in the morning and afternoon related to diabetes mellitus dated 08/06/21. Humalog (insulin) solution 100unit/ml inject 28 units SQ in the evening related to diabetes mellitus dated 08/06/21. Carvedilol (antihypertensive) tablet 3.125mg by mouth two times a day related to atrial fibrillation. Give with meal. Hold if pulse less than (<) or systolic (relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) blood pressure < 110. Notify charge nurse anytime medication is held dated 01/05/21. clonidine (antihypertensive) tablet 0.1mg by mouth two times a day related to hypertension dated 06/27/21. Hydrochlorothiazide (diuretic- medication to promote the formation and excretion of urine) tablet 25mg daily related for CHF and hypertension dated 06/18/21. Lasix (diuretic) tablet 20mg by mouth in the morning for weight gain related to CHF dated 08/02/21. Daily weight notifies physician of gain > three pounds (lbs.) in a day or five lbs. in a week, in the morning related to CHF, dated 01/05/21. Review of the Medication Administrative Record (MAR) for R17 from May 2021 through August 16, 2021 revealed carvedilol was given outside physician ordered parameters in July 2021 seven times out of 62 opportunities and August 2021 one time out of 32 opportunities. Review of daily weight monitoring reveled weight gain > than three lbs. on 05/24/21 to 05/25/21, weekly weight gain > than five lbs. from 06/09/21 to 06/15/21 and 06/22/21 to 06/29/21. Review of blood glucose monitoring revealed May 2021 documented four out parameters readings out of 25 opportunities; June 1, 2021 to June 7, 2021 documented three out of parameter reading out of 14 opportunities; June 8, 2021 to June 30, 2021 documented six out of parameter reading out of 92 opportunities. July 2021 documented nine out of parameter readings out of 124 opportunities; August 1, 2021 to August 16, 2021 documented two out of parameter readings out of 32 opportunities. The clinical record lacked documentation of physician notification. On 08/17/21 at 09:10 AM R17 sat in wheelchair in her room, ate her breakfast with out assistance as she watched TV. She denied pain and reported that her breakfast was good. On 08/18/21 at 01:46 PM in an interview, Licensed Nurse (LN) G stated all the antihypertensive medication do not have parameters for monitoring, all the beta blockers do. LN G stated that each physician has their own parameter guidelines. Nurse managers review all new orders and will call the physician for parameter orders. LN G stated that when a BP, blood glucose reading, and weight was out of parameter medication are held and the physician is notified and document that in the nurses note. On 08/18/21 at 02:23 PM in an interview, Administrative Nurse D stated all antihypertensive medications should have parameters. She stated if a BP, pulse, weight or blood glucose was out side the parameters medication should be held, and physician should always be notified. The facility Blood Glucose Monitoring policy dated 04/16/21 documented if a blood glucose level was above or below parameters set by the physician document the time the physician was notified. The facility Nurse Notification of Physician policy dated 04/16/20 documented record the following in the resident's clinical record: All attempts to notify the physician, time and any other individual spoken to; Assessment findings reported; Additional information provided: Physician response; Resident statue and response to the treatment. The facility Physician Orders for Medications and Treatment policy dated 04/16/20 documented all orders should have specific precautions or directions if needed; such as parameters. The facility failed to ensure the physician was notified of out of parameter daily and weekly weights, BP's, and blood glucose levels as ordered for R17. This placed her at risk of adverse consequences of possible fluid retention, which had the potential for adverse outcomes related to her CHF, hyperglycemia (greater than normal amount of glucose in the blood), and the potential for unnecessary medication use and unwarranted side effects for hypertension. - R24's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R24 was totally dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R24 had received antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment testing) and other mental emotional conditions) medication for seven days and opiod (a class of medication used to treat pain) medication for dour days during the look back period. The Quarterly MDS dated 07/04/21 documented a BIMS score of three which indicated severely impaired cognition. The MDS documented R24 was totally dependent upon two staff members assistance of for her ADL's. The MDS documented R24 received antipsychotic medication for seven days, antianxiety (class of medications that calm and relax people with excessive anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), nervousness, or tension) medication for two days, and opioid medication for five days. R24's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 04/09/21 documented she was frequently incontinent. R24's Care Plan dated 11/18/15 documented she required extensive assistance with toileting and was frequently incontinent of bladder and bowels. Review of the EMR under Tasks tab from May 1, 2021 to August 16, 2021 for Bowel Movements revealed no bowel movement documented from 05/29/21 to 06/02/21 (four days); 07/01/21 to 07/04/21 (four days); 07/23/21 to 07/26/21 (four days); 08/08/21 to 08/12/21 (five days). The clinical record lack documentation that any as needed medication (PRN) had been administered. Review of the EMR under the Orders tab revealed physician orders: Bisacodyl (laxative medication used to stimulate or facility evacuation of the bowels) suppository 10 milligram (mg) rectally PRN for bowel management., give one suppository daily if no BM in three days dated 04/05/18. Senna lax-s (laxative) tablet 8.6-50mg give two tablets by mouth in the morning for constipation dated 03/26/20. MiraLAX (laxative) give 17 grams by mouth in the morning for constipation, mix in four to eight ounces of water, and hold for loose stools dated 12/31/20. On 08/17/21 at 11:43 AM R24 sat in her wheelchair with her foot pedals on the wheelchairs in the activity room having her nails painted. No behaviors or distress noted. On 08/18/21 at 01:25 PM in an interview, Certified Nurse's Aide (CNA) M stated the CNA staff document the bowel movements in the EMR. CNA M stated that the nurse would give the resident something after three days. On 08/18/21 at 01:46 PM in an interview, Licensed Nurse (LN) G stated the night shift nurse reviews the EMR, makes a list of residents that have not had a BM in the past three days. LN G stated dayshift starts the bowel protocol per physician standing orders, which is different for each physician. LN G stated that if a medication was implemented from the physician standing orders the order would be documented on the medication administration record. On 08/18/21 at 02:23 PM in an interview, Administrative Nurse D stated bowel monitoring was done on every shift, night shift reviews the clinical record every night and given to the day shift nurse to implement the bowel protocol for that resident. Administrative Nurse D sated bowel protocol stated on day four with no bowel movement for three days. The policy Bowel Protocol policy dated 06/03/21 documented residents will be evaluated daily for bowel habits. Residents who fail to have a bowel movement in a three-day period will be identified and measures will be taken to ensure bowel health. The facility failed to ensure constant bowel monitoring was done for R24 which put her at risk for adverse consequences related to unnecessary medication and potential delay in identifying and treating constipation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 44 residents. The sample included 13 residents; five residents sampled for unnecessary medication review. Based on observations, record reviews, and interviews, the facility failed to provide behavior monitoring on two scheduled psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications and on an as needed (PRN) anxiolytic (antianxiety- class of medications that calm and relax people with excessive anxiety [mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear], nervousness, or tension) medication for Resident (R) 39. The facility failed to provide consistent behavior monitoring and failed to ensure a PRN anxiolytic medication had a specified timeframe and a physician stated need for continuation despite risk for R24. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use. Findings included: - The Diagnoses tab of R39's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and major depressive disorder (major mood disorder). The admission Minimum Data Set (MDS) dated [DATE], documented R39 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. R39 received antianxiety medication one day and antidepressant medications seven days in the seven-day look back period of the assessment. The Psychotropic Drug Use Care Area Assessment (CAA) dated 08/04/21, documented R39 took antidepressant and antianxiety medications. Remeron (antidepressant- class of medications used to treat mood disorders and relieve symptoms of depression) and Zoloft had black box warnings (BBW- warnings required by the Food and Drug Administration for certain medications that carry serious safety risks) and staff were to monitor for unusual changes in behavior and/or suicidal ideations. The Care Plan dated 07/30/21, documented R39 had a history of depression and anxiety that she took medication for. The Care Plan dated 07/29/21, documented R39 took medications that had black box warnings and directed staff monitored R39 for significant reactions that could occur and notify physician immediately if any occurred. The Orders tab of R39's EMR documented an order with a start date of 07/30/21 and an end date of 08/13/21 for lorazepam (antianxiety) 0.5 milligrams (mg) every six hours as needed for anxiety and terminal agitation for 14 days, an order with a start date of 07/29/21 for sertraline (Zoloft- antidepressant) 100 mg every morning for major depressive disorder, and an order with a start date of 07/29/21 and end date of 08/11/21 for mirtazapine (Remeron- antidepressant) 7.5 mg at bedtime for major depressive disorder. The Orders tab lacked an order for behavior monitoring for lorazepam, sertraline, or mirtazapine. Review of the Treatment Administration Record (TAR) lacked evidence of behavior monitoring for psychotropic medications. The Tasks tab of R39's EMR lacked a task for behavior monitoring for psychotropic medications. On 08/17/21 at 01:49 PM, R39 laid in bed with her eyes closed, she had a visitor sitting at bedside. She appeared comfortable and without signs of distress or discomfort. No behaviors noted. On 08/18/21 at 01:25 PM, Certified Nurse Aide (CNA) M stated if a resident had a history of behaviors then they had behavior monitoring and the aides charted on behaviors in Point of Care (POC- CNA charting system). On 08/18/21 at 01:46 PM, Licensed Nurse (LN) G stated all nursing staff monitored behaviors but mostly the CNAs who reported behaviors to the nurse. The nurse charted behaviors in the TAR and any resident on a psychotropic medication had behavior monitoring. On 08/18/21 at 02:23 PM, Administrative Nurse D stated behavior monitoring was completed every shift by the nurse and documented on the TAR. She stated behavior monitoring was completed on any resident that received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) or antidepressant medications. The facility's Behavior Monitoring policy, dated 08/11/21, directed the facility monitored residents for behaviors who received antipsychotic and anxiolytic medications. The policy directed the resident was monitored for the behavior the medication was prescribed for. The facility failed to provide behavior monitoring for psychotropic medication use for R39. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use. - R24's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R24 was totally dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R24 received antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment testing) and other mental emotional conditions) medication for seven days and opioid (a class of medication used to treat pain) medication for four days during the look back period. The Quarterly MDS dated 07/04/21 documented a BIMS score of three which indicated severely impaired cognition. The MDS documented R24 was totally dependent upon two staff members assistance for her ADL's. The MDS documented R24 received antipsychotic medication for seven days, antianxiety (class of medications that calm and relax people with excessive anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension) medication for two days, and opioid medication for five days. R24's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/09/21 documented she received an antipsychotic medication. R24's Care Plan dated 05/30/19 documented dose reduction of antipsychotic medications at intervals per recommendation by consultant pharmacist and as directed by the physician. Review of the EMR under Orders tab documented physician orders: Seroquel (antipsychotic) tablet 50 milligram(mg) two times a day for sundowners/aggressive behavior dated 06/17/21 Lorazepam (antianxiety) concentrate 2mg/milliliter (ml) by mouth every four hours as needed for anxiety dated 07/23/21. Behavior: verbal aggression medication: Seroquel = Number of behaviors noted during this shift. INT = Intervention code from list below, that was tried. OTCM = Outcome of interventions, use code listed below. INTERVENTION CODE: 1. Redirection 2. 1:1 3. Activity 4. Toileted 5. Food/Fluids 6. Change of position 7. Assess/Medicate Pain 8. Adjust room temperature 9. See Nurses note OUTCOME: Improvement (+) Worse (-) No Change (NC) every shift. Review of the Medication Administration Record (MAR) from May 2021 through August 2021 revealed lack of documentation for Behavior Monitoring May 2021 for three shifts out of 93 opportunities; June 2021 two shifts out of 90 opportunities; July 2021 for two shifts out of 93 opportunities. Review of Medication Regimen Review (MRR) dated 08/10/21 sent by the facility lacked a specified duration of use and risk verses benefit statement or therapeutic rationale for continued use for R24's antianxiety medication. On 08/17/21 at 11:43 AM R24 sat in her wheelchair with her foot pedals on the wheelchairs in the activity room having her nails painted. No behaviors or distress noted. On 08/18/21 at 01:25 PM, Certified Nurse Aide (CNA) M stated if a resident had a history of behaviors then they had behavior monitoring and the aides charted on behaviors in Point of Care (POC- CNA charting system). On 08/18/21 at 01:46 PM, Licensed Nurse (LN) G stated all nursing staff monitored behaviors but mostly the CNAs who reported behaviors to the nurse. The nurse charted behaviors in the TAR and any resident on a psychotropic medication had behavior monitoring. LN G stated PRN psychotropic medications should have stop date. On 08/18/21 at 02:23 PM, Administrative Nurse D stated behavior monitoring was completed every shift by the nurse and documented on the TAR. She stated behavior monitoring was completed on any resident that received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) or antidepressant medications. Administrative Nurse D stated anyone on a PRN psychotropic medication needed a 14 day stop date. The facility Behavior Monitoring policy, dated 08/11/21, directed the facility monitored residents for behaviors who received antipsychotic and anxiolytic medications. The policy directed the resident was monitored for the behavior the medication was prescribed for. The facility Physician Orders for Medications and Treatments policy dated 04/16/20 documented that physician orders will include duration of administration. The facility failed to ensure behavior monitoring for antipsychotic medication and duration of PRN antianxiety medication for R24, which placed her at risk from unnecessary antianxiety medication administration, thus leading to possible harmful potential side effects.

The facility identified a census of 44 residents. Based on observation, record review, and interview, the facility failed to perform hand hygiene properly between serving residents at meals, and in between doffing (removing) gloves and donning (putting on) new gloves. The facility failed to provide a clean barrier under the glucometer (instrument used to calculate blood glucose) while obtaining blood glucose reading. The facility failed to ensure staff practiced infection control standards during wound care. This deficient practice placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - Observation on 08/16/21 at 11:19 AM, Certified Nurse Aide (CNA) N was in the dining room, grabbed a plate from the serving window and delivered it to a resident, no hand hygiene observed before or after serving this resident. Observation on 08/16/21 at 11:21 AM revealed CNA N propelled a male resident into the dining room and placed the resident at a table. CNA N got juice and ice in a cup, placed a lid on the cup and delivered it to resident, then placed a napkin on the resident's lap. CNA N then grabbed an electronic tablet from the counter and used it to put in a lunch order for a resident after helping this resident. No hand hygiene noted during this observation or after putting tablet down. Observation on 08/16/21 at 11:30 AM revealed CNA N, delivered a tray to a resident, placed a napkin on the resident's upper body, touched the resident's shoulder to comfort her, then grabbed a cup out of a drawer and. He placed ice int he cup and then covered the cup with saran wrap and exited the dining room. No hand hygiene was observed after touching the resident and before touching cups, or before he left the dining room. Observation on 08/18/21 at 09:27 AM revealed Licensed Nurse (LN) H performed wound care on a resident. She gathered her supplies and placed them directly on the resident's bed (no barrier on bed), no hand hygiene seen before doing so. LN H then sat directly on resident's floor and placed a bag in the trash can and began removing ace wraps (without gloves on) and placed the wraps directly on the bed (no barrier on bed); she then removed gauze wrap and placed on bed as well (no barrier on bed). She placed clean items on a clean chux (protective barrier) on the floor. She then donned gloves and removed soiled dressing, then cleansed wound area twice, she got up from the floor, doffed dirty gloves, went to resident's drawer in room to get new gauze sock dressing (no hand hygiene done). She sat back down on the floor and donned clean gloves and place a new dressing on wound, and then wrapped two kerlix wraps and two ace wraps to legs (no hand hygiene seen after). Observation on 08/18/21 at 11:58AM revealed LN H obtained a finger stick blood sugar (FSBS) from a resident. LN H entered the room carrying a tray with supplies in it and placed the tray directly on the end table (no protective barrier underneath). She placed the glucometer on the bedside table (no barrier used). She donned gloves, completed the process of obtaining blood glucose test, then she moved the glucometer from bedside table to end table (no barrier present on table). She cleaned the glucometer and doffed her gloves (no hand hygiene notice after). In an interview on 08/18/21 at 1:25 PM, CNA M stated hand hygiene should be done after everybody, after cares, after taking a resident to the restroom, after getting a resident dressed, hand hygiene between donning and doffing gloves. She also stated she would sanitize hands between passing trays at meals or after touching the tablet. In an interview on 08/18/21 at 1:36 PM Certified Medication Aide (CMA) R stated hand hygiene should be done after cares, between passing medications, between doffing and donning gloves. On 08/18/21 at 12:03 PM in an interview with LN H, she stated she does not place a barrier between the glucometer and the bedside table, since she had cleaned the machine prior to and after each use. LN H stated that she should have hand satanized or washed her hands between donning and doffing gloves during the dressing change. In an interview on 08/18/21 at 1:46 PM LN G stated hand hygiene should be done when hands are soiled, before dressing changes, before/after toileting a resident, after meals. Hands should be sanitized in between glove changes, between meal trays and after touching residents. She further stated that when doing FSBS on a resident the glucometer should be placed on top of a barrier on the bedside table and cleaned before/after each glucometer use. In an interview on 08/18/21 at 2:13 PM with Administrative Nurse and Infection Control Preventionist E, she stated all staff do hand hygiene education and skills check off upon being hired and annually. She would expect hand hygiene to be done before entering a room, before/after cares, when gloves are soiled, between donning/doffing glove. Hand hygiene should also be done between touching resident and the tablets at meals in the dining room. The facility policy Infection Control, dated 04/04/21, documented: The facility will facilitate sage care of all residents and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Standard and transmission-based precautions to be followed to prevent spread of infections. Hand hygiene procedures to be followed by staff involved in direct resident contact. The facility policy Hand Hygiene dated 04/08/21 documented: All staff member will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare associated infection (HAIs). Indications for hand washing: Hand washing/ alcohol based hand rubbing may also be used for routinely decontaminated hands such as; before and after having direct contact with patients, before and after contact with medical equipment in the immediate vicinity of the resident, after removing gloves, before and after assisting a resident with eating. The facility policy Dry/Clean Dressing dated 11/05/15 documented: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps to follow included: Establish a clean field; place clean equipment on clean field; have a plastic bag available for trash; wash and dry hands thoroughly; put gloves on, removed soiled dressing; pull glove over dressing and discard into plastic bag; wash and dry hands; open dry, clean dressings; pour prescribed cleansing solution over the dry gauze; put on clean gloves; cleanse wound; use dry gauze to pat wound dry; apply ordered dressing/s and secure; discard disposable items in to bag; remove gloves and discard into bad; wash and dry hands. The facility policy Blood Glucose Monitoring dated 04/16/21 documented: general infection control guidelines included providing clean barriers between equipment caddy and resident furnishings/bedding and the equipment was cleaned/sanitized if contaminated during procedure. The facility failed to ensure staff demonstrated proper use of hand sanitizer/hand washing in between residents while providing services to residents in the dining area. The facility failed to ensure staff used a protective barrier on resident's tables/bedside tables and bed while providing wound care and obtaining a blood glucose reading. The facility also failed to ensure staff did proper hand hygiene between doffing soiled gloves and donning clean gloves during wound care. These facility failures had the potential to spread infection and disease to all residents of the facility.