**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for one resident, Resident (R)40, whose hydrochlorothiazide (HCTZ-a diuretic) was discontinued. This placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of bradycardia (low heart rate, less than 60 beats per minute), cerebrovascular accident (CVA-stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease ( longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypotension (low blood pressure), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], documented R40 had moderately impaired cognition and required substantial assistance with all activities of daily living (ADLs). R40 received insulin (a hormone that lowers the level of glucose in the blood), antidepressant (a medication used to treat depression), anticoagulation ( a class of medications used to prevent the blood from clotting), and a diuretic (a medication used to promote the formation and excretion of urine) daily. R40's Medicare 5-Day MDS, dated 11/05/24, documented R40 had severely impaired cognition and was dependent upon staff for toileting, bathing, lower body dressing, and transfers. R40 required substantial assistance for eating, upper body dressing, and mobility. R40 received antidepressant and anticoagulation medication daily. R40's Care Plan, dated 10/21/24 and initiated on 01/26/22, documented R40 had a history of chronic kidney disease and directed staff to monitor and report changes in mental status, and any weight gain of over two pounds per day. The update, dated 11/19/23, documented R40 had a history of CVA and hypertension, and directed staff to administer hydrochlorothiazide (HCTZ-a diuretic) and lisinopril (a medication used to lower blood pressure) as ordered and monitor for weight changes; notify the physician of any abnormal readings. The update, dated 02/13/24, documented R40 was on HCTZ for diuretic therapy and directed staff to administer medication as ordered, and monitor for any adverse consequences like hypotension and fatigue. Staff were to report pertinent lab results to the physician. R40's Hospital Discharge Summary, dated 10/08/24, documented that R40 was admitted to the hospital on [DATE] for bradycardia, acute kidney injury, and to rule out a CVA. The discharge summary directed staff to discontinue R40's HCTZ, 25 milligrams (mg), and lisinopril, 20 mg, per the physician's request. R40's Medication Administration Record, (MAR) dated 10/09/24, documented R40 received both 25 mg HCTZ and 20 mg of lisinopril at the 06:00 AM medication time. On 11/18/24 at 08:15 AM, observation revealed R40 lay in bed with his eyes closed. On 10/20/24 at 01:30 PM, Administrative Nurse D verified the interdisciplinary team worked on the care plans and verified the diuretic therapy care plan for R40's HCTZ should have been taken off the care plan when the medication was discontinued. The facility's Using the Care Plan policy, dated 10/2024, documented care plans should be used in developing the resident's daily care routines and would be available to staff personnel who have the responsibility for providing care or services to the resident. Completed care plans were available to the staff located per facility protocol and utilized to generate resident-specific information. Changes in the resident's condition would be reported to the MDS Assessment Coordinator for applicable review of the care plan, Information contained in the care plan and other documents used by the nursing staff shall be maintained confidentially by established facility policy. The facility failed to revise R40's Care Plan when R40's HCTZ medication was discontinued. This placed the resident at risk for inappropriate care due to uncommunicated care needs.

The facility had a census of 64 residents. The sample included 17 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication with the dialysis provider regarding dialysis treatments and monitoring for Resident (R)54. This placed the resident at risk for complications and health decline. Findings included: - R54's Electronic Health Record (EHR) documented R54 had a diagnosis of stage four chronic kidney disease (CKD- a critical phase when kidneys are severely damaged and can't filter waste from the blood properly). R54 Annual Minimum Data Set (MDS), dated 9/21/24, recorded R54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R54 required setup assistance with eating, upper and lower body dressing, putting on and taking off footwear, personal hygiene, sitting to lying, supervision with oral hygiene, toileting hygiene, showering, rolling left to right, lying to sitting on side of the bed, and sit to stand activity. R54 required supervision with oral hygiene, toileting hygiene, showering, transfers, and ambulation without a mobility device. The MDS recorded the resident received dialysis treatment. R54's Care Plan, dated 09/21/24, documented that R54 received dialysis three times a week on Monday, Wednesday, and Friday. R54's EHR revealed Dialysis Communication Form, from 09/04/24 to 11/18/24 lacked completed information from the dialysis center regarding the resident's treatment, monitoring, or orders. On 11/18/24 at 01:33 PM, observation revealed R54 sat quietly in a recliner in his room. On 11/20/24 at 12:19 PM, Administrative Nurse D stated the facility sent a communication sheet to the dialysis center but verified the facility did not receive the communication sheet information back from the dialysis center. Administrative Nurse D said if there was a change or staff needed to know anything, the dialysis center would call them. The facility's Dialysis Policy, revised 10/24, documented communication between the facility and the dialysis facility shall contain the following: Information if the medication was administered not according to orders or plan of care. New orders and results of labs. Current vital signs and weights. Advanced Directives and code status. Nutritional and fluid management, including residents' compliance with diet, during and /or after dialysis. Response to dialysis and any behaviors that may impede the treatment. Changes or declines in condition unrelated to dialysis and recommendations for monitoring. Concerns for vascular access site; and concerns and risks regarding transport to dialysis. The facility failed to ensure ongoing communication with the dialysis provider regarding R54's dialysis treatments. This placed the resident at risk for complications and health decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 17 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to obtain written informed consent which included potential risks versus benefits from the resident and/or representative for the use of side rails for Resident (R)10. This placed her at risk for accident or injury due to uninformed choices regarding side rail use. Findings included: - The Electronic Medical Record (EMR) for R10 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had severely impaired cognition and had inattention and disorganized thinking daily. R10 was dependent on staff for toileting, mobility, and transfers. R10 had lower-body impairment on one side. The MDS documented that R10 used side rails. R10's Side Rail Assessments, dated 09/09/24, 06/06/24, 03/09/24, and 12/09/23, documented no alternative to bed rails was attempted as she used the rails to pull or push for mobility; no alternatives were attempted, and failed; negative physical outcomes were discussed with R10's representative, and the care plan was updated. The assessments noted that R10's family demanded the side rails despite the risks. R10's Care Plan, dated 08/17/24 and initiated on 02/21/24, documented that R10 had a hospital bed with quarter-rails up for safety during care and to assist with bed mobility. The plan directed staff to observe for injury or entrapment (being caught in or as in a trap) related to side rail use and reposition as needed to avoid injury. The update, dated 08/19/24, documented that R10 used side rails to assist in entering and exiting the bed safely, moving up and down in bed, turning side to side, and pulling herself from a lying position to a sitting position. The care plan documented that side rail precautions were discussed and consent from the family had been obtained. The Physician's Order, dated 06/06/23, ordered a hospital bed with quarter-rails per Durable Power of Attorney (DPOA) preference. The facility's Risk versus Benefits dated 09/07/23, documented the form was for two side rails on R10's bed, and the form documented that if it were signed, the responsible party assumed full responsibility for all possible risks associated with not complying with the recommendations of the skilled professionals of the facility. The form further documented there were other risks from the decision to not comply with the mentioned treatment or recommendations, up to and including death: loss of dignity, pain, serious injury, loss of movement or function, abnormal movements, hospitalization, serious skin problems, falls, broken bones, and possible entrapment of head or body in the side rails. The form indicated that the DPOA signature on the form indicated the non-compliance was clearly explained to them and that they comprehended everything. The form lacked a signature from the resident or responsible party but documented the facility spoke to the responsible party and the physician via phone. The form was signed by Administrative Nurse D and Administrative Nurse E. On 11/19/24 at 08:00 AM, observation revealed R10's bed with quarter-rails on both sides. Both rails had an opening approximately 18 inches by 15 inches. Continued observation revealed the bed rail was attached to the bed frame. On 11/19/24 at 09:15 AM, Administrative Nurse D stated the facility verbally explained the risks of the quarter-rails used on R10's bed to her family, and the family was very insistent that she have them. Administrative Nurse D stated that R10's family was very involved in her care and the bed rails were discussed in her care plan meetings. Administrative Nurse D confirmed the facility had not obtained a signed risk versus benefits from R10 or her responsible party. The facility's Use of Physical Restraints, Including Bedrails policy, dated 08/24, documented restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should only be used to treat the resident's symptoms and never for discipline or staff convenience, or for the prevention of falls. Examples of devices that are/may be considered physical restraints include: using bedrails that keep the resident from voluntarily getting out of bed safely due to their physical or cognitive inability to lower the bed rail independently. Before placing a resident in restraints, there should be a pre-restraint assessment and review to determine the need for restraints, The assessment should be used to determine if there are fewer restricted interventions. Restraints should only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, the order alone was not sufficient to use the restraint. The order shall include the specific reason for the restraint, how the restraint would be used to benefit the resident's medical symptoms, the type of restraint, and the period for the use of the restraint. Restrained residents should be reviewed at least quarterly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. The care plan should include the measures taken to systematically reduce or eliminate the need for restraint use, and interventions that address not only the immediate medical symptom but the underlying problems that may cause the symptoms. Bed rail use would be based on resident preference and medical symptoms. The facility failed to obtain written informed consent from R10 or her representative for using side rails. This placed her at risk for accident or injury due to uninformed choices associated with side rail use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Certified Nurse Aide (CNA) staff possessed adequate competency and skill for the use of a slide board for one resident, Resident (R) 6, who was lowered to the ground during a slide board transfer. This placed the resident at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting the left non-dominant side, muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), and obesity (excessive body fat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition and was dependent on staff for toileting, showers, lower body dressing, and transfers. R6 required substantial assistance from staff for mobility and upper body dressing. R6 had upper and lower functional impairment on one side, had one noninjury fall, and had not received therapy. The Fall Assessments, dated 10/02/24, 07/03/24, 04/03/24, and 01/02/24, documented R6 had a high risk for falls. R6's Care Plan, dated 08/29/24 and initiated on 10/22/15 documented R6 was at risk for falls related to a history of falls, hemiplegia to his left side, and generalized muscle weakness. The update, dated 11/22/23, directed staff to encourage exercise and mobility to maximize and maintain balance, strength, and coordination. Staff were to, answer his call light promptly, use a gait belt when assisting the resident with mobility, and make sure he wore appropriate shoes or nonslip socks when not in bed and during all transfers. The care plan directed staff to monitor for any changes in his mental, emotional, or physical condition. The update dated 05/29/24, directed staff to transfer R6 with two staff and to use the Beasy transfer board (a portable slide board transfer system that has a circular seat that rotates 360 degrees to easily turn the user to the exact angle, allowing the smallest caregiver ability to transfer someone up to 400 pounds (lbs.) using a smooth lateral glide), gait belt, and have his right leg leading. The care plan documented that if the nurse determined R6 was too weak to transfer with the Beasy board, use a Hoyer (full mechanical body lift) and two staff for transfers. The Fall Investigation, dated 10/22/24, documented R6 was on the floor beside his bed, propped up with his right arm. Certified Nurse Aide (CNA) M reported that while in the room, she performed a two-person transfer, using a gait belt and slide board. R6 became weak, so the CNA lowered him to the floor. R6 stated he became weak, his legs went out, and staff slid him down to the floor. R6 did not sustain an injury, had on proper footwear, and denied any pain. The investigation documented the care plan was followed. The investigation documented a statement from CNA M was obtained, and the Director of Nursing (DON) educated the CNA that if R6 experienced weakness, staff were to use the Hoyer lift for transfers. The Assisting with Transfers To/From a Bed Competency, dated 10/22/24, did not state CNA M was observed for a transfer with a slide board. It documented CNA M was observed for a Hoyer lift transfer with a different resident than the resident she had the fall with. The competencies provided did not include any training or observation for a transfer with the slide board. On 11/19/24 at 01:10 PM, observation revealed CNA M and CNA O tried to find a gait belt that fit appropriately around R6's waist. CNA M stated she had used a gait belt around his waist earlier but put it in the laundry so now they had to find one to fit him. CNA M and CNA O both tried three different gait belts on R6 but they were all too short, so CNA O left and found one that was appropriate for R6's size. CNA M lowered R6's bed, placed the wheelchair flush with the side of the bed, and removed the right armrest from the wheelchair. CNA M took the flat, wooden slide board that lacked a circular seat which rotated and attempted to place it under R6's right buttocks (the round fleshy part that forms the lower rear area of a human trunk) but it did not slide under him easily. CNA M grabbed the gait belt to assist R6 in lifting his right buttock and it took CNA O to assist CNA M with lifting. The CNA was then able to quickly slide the wooden transfer board under R6's right side. Continued observation revealed the weight of the resident on the slide board caused it to lift off of the bed on one end, and CNA O stated that staff had to use two hands on it to hold it down so the resident could slide over. CNA O held down the slide board and CNA M assisted R6 to slide over onto the bed. R6's feet were placed on the bed, and he was provided his call light. On 11/19/24 at 01:30 PM, CNA O stated she was the restorative aide who worked all over the building. CNS O said if a resident required the use of a lift or slide board, therapy would train staff on how to do it. On 11/19/24 at 01:40 PM, Administrative Nurse D stated that R6 was a big man and that the description of the transfer with the slide board did not sound like the transfer was done correctly. On 11/19/24 at 02:15 PM, Consultant HH stated R6 was last evaluated in February of 2024 for the use of the slide board and stated staff were trained on how to use it at that time. Consultant HH further stated that any new CNAs would be trained by the other CNAs on how to use the slide board with R6. On 11/19/24 at 4:40 PM, CNA M stated she was the CNA with R6 when he was lowered to the ground. CNA M stated she had a gait belt around him, and she and another CNA started to transfer him with the slide board but he said he was weak and would not make it, so she lowered him to the ground. CNA M explained that R6 did not stand well, his legs were weak and that he was too far past the wheelchair to be placed back in the chair, so she lowered him to the floor instead. CNA M further stated she couldn't get R6 to the bed or back to the wheelchair before she had to lower him to the floor. CNA M stated she had to watch computer training on transfers and had to demonstrate a transfer to the Director of Nursing, On 11/20/24 at 01:00 PM, Administrative Nurse D stated she did not watch CNA M transfer R6 with the slide board but had CNA M tell her how R6 was transferred; she watched CNA M do transfers with other residents. Administrative Nurse D stated she did not get a statement from the second CNA nor could she remember who the second CNA was, therefore that second CNA was not provided with reeducation on transfers with slide boards. Administrative Nurse D could not explain what the second CNA was doing while CNA M was trying to transfer R6. The facility's Staff Competency policy, dated 06/24, documented all nurse aide personnel shall participate in regularly scheduled in-service training classes. Nursing staff would demonstrate competency in skills and techniques necessary to care for the resident's needs, as identified through resident assessments and resulting plans of care. The facility failed to ensure CNA staff possessed adequate competency and skill for the use of a slide board for R6, who was lowered to the ground during a staff-assisted slide board transfer. This placed the resident at risk for injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R38's Electronic Medical Record (EMR) documented that R38 had a diagnosis of atherosclerosis (a buildup of fats, cholesterol, and other substances in and on the artery walls) of the coronary arteries (blood vessels of the heart). R38's Annual Minimum Data Set (MDS), dated [DATE], documented R38 had a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R38 had atherosclerosis. R38's Care Plan, revised 9/20/24, instructed staff to administer medications as the physician ordered. The plan documented that R38 received amiodarone (a medication that prevents and treats an irregular heartbeat) and instructed staff to hold the medication and call the physician if R38's heart rate was less than 60 beats per minute (BPM), or her blood pressure (BP) was less than 90 diastolic (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading). The Physician Order, dated 09/12/24 at 06:00 AM instructed staff to administer amiodarone HCl, 200 milligrams (mg) tablet, by mouth, one time a day and to notify the physician of R38's heart rate was less than 60 BPM or her DBP less than 90. R38's clinical record revealed R38's DBP was less than 90 and lacked documentation the physician was notified daily from 09/12/24 through 11/13/24. R38's clinical record revealed R38's pulse was less than 60 BPM and lacked documentation the physician was notified on the following dates: 10/06/24-58 BPM 10/25/24-58 BPM 10/30/24- 57 BPM 11/04/24-57 BPM The Consultant Pharmacist (CP) Regimen Review from 09/27/24 to 11/13/24 lacked documentation the pharmacist identified the above findings regarding R38's blood pressure and pulse monitoring being out of ordered parameters with no physician notification. On 11/18/24 at 04:25 PM, observation revealed R38 sat quietly in a wheelchair in the dining room and visited with other residents in a polite voice at her table. On 11/20/24 at 11:16 AM, Administrative Nurse D verified the CP had not alerted the facility regarding R38's irregularities for blood pressure and pulse monitoring outside of the physician-ordered parameters for the dates listed. The facility's Pharmacist Services Overview policy, dated October 2024, recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. The facility would contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility, the Medical Director, and the Attending Physician. The facility failed to ensure the CP identified and reported to the facility irregularities in R38's blood pressure and pulse monitoring. This placed the resident at risk for unnecessary medication side effects. The facility had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 37's use of an antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality)and irregularities with R38's blood pressure and pulse monitoring. This placed the resident at risk for unnecessary medications and related side effects. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness). R37's Annual Minimum Data Set (MDS), dated [DATE] recorded R37 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS recorded R37 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic [alters mood or thought] Drug Use Care Area Assessment (CAA), dated 11/11/24, recorded R37 had a history of decreased appetite, depression, anxiety, and dementia. R37 received Seroquel, (an antipsychotic) clonazepam (an antianxiety medication), Remeron (an antidepressant), and sertraline (an antidepressant). R37's Care Plan, dated 11/07/24 recorded R37 received antipsychotic medication for the diagnosis of dementia, personality disorder, and anxiety. Staff were to monitor for side effects and effectiveness. The plan documented the facility would consult the physician to consider dose reduction when clinically appropriate. The Physician's Order, initial order date 09/09/24, directed the staff to administer Seroquel 25 milligrams (mg), twice daily for a diagnosis of unspecified dementia, moderate with other behavioral disturbances. R37's EMR lacked a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the Seroquel use. The Consultant Pharmacist Monthly Medication Review (MMR) dated 12/28/23 R37 received Seroquel with a diagnosis of anxiety and that was an inappropriate diagnosis or indication. The recommendation indicated changed but lacked what the new diagnosis was. The CP MMRs dated 01/30/24, 02/22/24, 03/28/24, 04/24/24, and 05/30/24 documented Seroquel has been associated with metabolic changes including weight gain and dyslipidemia (abnormal cholesterol levels) and recommended the facility should evaluate the continued use of Seroquel. The CP MMR dated 06/20/24, 07/24/24, 08/27/24, 09/27/24, 10/18/24, and 11/13/24 did not make any recommendations related to the continued use of Seroquel. On 11/18/24 at 04:15 PM, observation revealed the resident sat on the side of her bed. Continued observation revealed Certified Medication Aide (CMA) R administered the resident's medications which included the Seroquel. On 11/20/24 at 08:20 AM, Administrative Nurse D verified that R37 received Seroquel with a diagnosis of dementia with behavioral disturbance which she thought was an appropriate indication for the medication. Administrative Nurse D stated the pharmacist completed monthly reviews and sent them to the facility with concerns and recommendations. Administrative Nurse D said that a few months ago, R37's Seroquel had a diagnosis of anxiety. Administrative Nurse D said that was identified and the diagnosis was changed to dementia with behavioral disturbances. The facility's Pharmacist Services Overview policy, dated October 2024, recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. The facility would contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility, the Medical Director, and the Attending Physician. The facility failed to ensure the CP identified and reported the unapproved indication for the continued use of R37's antipsychotic medication, Seroquel. This placed R37 at risk for unnecessary psychotropic medication and related side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 17 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician when Resident (R) 38's blood pressure and pulse were outside the physician-ordered parameters. This placed the residents at risk for ineffective medication regimens and unnecessary medication side effects. Findings included: - R38's Electronic Medical Record (EMR) documented that R38 had a diagnosis of atherosclerosis ( a buildup of fats, cholesterol, and other substances in and on the artery walls) of the coronary arteries (blood vessels of the heart). R38's Annual Minimum Data Set (MDS), dated [DATE], documented R38 had a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R38 had atherosclerosis. R38's Care Plan, revised 9/20/24, instructed staff to administer medications as the physician ordered. The plan documented that R38 received amiodarone (a medication that prevents and treats an irregular heartbeat) and instructed staff to hold the medication and call the physician if R38's heart rate was less than 60 beats per minute (BPM), or her blood pressure (BP) was less than 90 diastolic (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading). The Physician Order, dated 09/12/24 at 06:00 AM instructed staff to administer amiodarone HCl, 200 milligrams (mg) tablet, by mouth, one time a day and to notify the physician of R38's heart rate was less than 60 BPM or her DBP less than 90. R38's clinical record revealed R38's DBP was less than 90 and lacked documentation the physician was notified daily from 09/12/24 through 11/13/24. R38's clinical record revealed R38's pulse was less than 60 BPM and lacked documentation the physician was notified on the following dates: 10/06/24-58 BPM 10/25/24-58 BPM 10/30/24- 57 BPM 11/04/24-57 BPM On 11/18/24 at 04:25 PM, observation revealed R38 sat quietly in a wheelchair in the dining room and visited with other residents in a polite voice at her table. On 11/20/24 at 12:19 PM, Administrative Nurse D verified R38's above findings and stated she put the order in wrong, but staff should have been following the physician's order to call for bp and pulses out of parameters. The facility's Guidelines for Notifying Physicians of Clinical Problems Policy, revised 10/24, documented the charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management. The facility failed to ensure R38's drug regimen was free from unnecessary drugs when staff failed to notify the physician when R38 ' s BP and pulses were out of physician-ordered parameters. This placed the residents at risk for ineffective medication regimens and unnecessary medication side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)37's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R37 at risk for unintended effects related to psychotropic (alters mood or thought) medications. Findings include: - R37's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness). R37's Annual Minimum Data Set (MDS), dated [DATE] recorded R37 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS recorded R37 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/11/24, recorded R37 had a history of decreased appetite, depression, anxiety, and dementia. R37 received Seroquel (an antipsychotic), clonazepam (an antianxiety medication), Remeron (an antidepressant), and sertraline (an antidepressant). R37's Care Plan, dated 11/07/24 recorded R37 received antipsychotic medication for the diagnosis of dementia, personality disorder, and anxiety. Staff were to monitor for side effects and effectiveness. The plan documented the facility would consult the physician to consider dose reduction when clinically appropriate. The Physician's Order, initial order date 09/09/24, directed the staff to administer Seroquel 25 milligrams (mg), twice daily for a diagnosis of unspecified dementia, moderate with other behavioral disturbances. R37's EMR lacked a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the Seroquel use. On 11/18/24 at 04:15M, PM observation revealed the resident sat on the side of her bed. Continued observation revealed Certified Medication Aide (CMA) R administered the resident's medications which included the Seroquel. On 11/19/24 at 08:20 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of dementia with behavioral disturbances which she thought was an appropriate indication for the medication. Administrative Nurse D verified the physician had been informed of the need for another diagnosis a few months ago when the diagnosis was anxiety, and it was changed at that time to dementia with behavioral disturbance. The facility's Psychotropic Drug Use policy dated April 2024, recorded that residents would receive antipsychotics and psychotropic medications when necessary to treat conditions for which they are indicated and effective and will not be used to discipline or convenience of the staff. Residents and their representatives have the right to refuse such treatment. The facility would review the diagnoses for which the medication classes are being utilized. If they are being utilized for other than their original approved indication, then apply the psychotropic monitoring. The physician's order would include diagnosis, condition, or symptoms for what is being ordered, and monitoring. The facility would complete an evaluation of the resident prior to starting a standing order of a psychotropic. This includes goals of therapy, reason for use (indication, diagnoses); and non-pharmacological interventions attempted, but the resident's quality of life is negatively impacted by the non-use of the medications. During the comprehensive, person-centered care planning process, the resident and/or their representative should be informed of the prescribed treatment. If the resident and/or their representative refuses the treatment, the IDT member (including the physician) should inform the resident about the risks for refusal and discuss appropriate alternatives, such as offering the medication at a different time, in another dosage form, or an alternative medication or non-pharmacological approach if available and document such in the clinical record. Identify and note non-pharmacological approaches as an alternative to or an adjunct to as-needed psychotropic use, and address them in the care plan. The facility would obtain psychotropic consent for new orders, and review and document the resident's target symptoms in the clinical record of anti-depressants, anti-anxiety, and anti-psychotic medications. The nursing anti-psychotic review would be completed at the following schedule: upon admission, if the antipsychotic medication is prescribed; on the addition of any new antipsychotic medication, and at least monthly. Gradual dose reduction would be conducted per CMS guidelines. The facility failed to ensure R37 did not receive antipsychotic medication without an appropriate indication or the required physician documentation for its use. This placed R37 at risk for unintended effects related to psychotropic medications.

The facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for two residents that retained both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition or decreased quality of life. Findings included: - On 11/18/24 at 08:15 AM, observation revealed staff preparing and serving the breakfast meal to residents in the dining room. On 11/19/24 at 10:45 AM, observation revealed Dietary Staff (DS) CC prepared two pureed diets. DS CC placed two servings of California medley blend vegetables (cauliflower, broccoli, and carrots) into the Robot-coup blender (food processor) and added one tablespoon (tbsp) plus 1/8 teaspoon (tsp) of food thickener, one tbsp plus ¾ tsp of left-over vegetable juice and blended the food to the correct consistency. DS CC then placed the food in a metal pan and placed the pan in the hot water well on the hot holding cart. Observation revealed DS CC then placed three three-ounce servings of meatloaf, topped with ketchup, in the Robot-coup and blended the food to the correct puree texture. DS DD then placed the food into a metal pan in the hot water well in the hot holding cart. (DS CC stated she added a little more because one of the residents may want an extra serving. The other food on the lunch menu, potatoes, and gravy, was at the correct puree texture. DS CC did not prepare the last menu item, a bread roll. On 11/19/24 at 02:00 PM, DS BB verified DS CC did not use a recipe when preparing the meatloaf and verified DS CC did use a recipe to puree the vegetables. An interview with DS BB verified DS CC did not puree the rolls for the residents like the other residents received. DS BB stated he realized that DS CC had not pureed and provided the bread roll and said that DS CC was corrected and had prepared two pureed bread rolls and provided them to the residents who received a pureed diet after the surveyor observation ended. DS BB stated the residents do not eat the pureed rolls due to the texture of the food. The facility's Food Preparation and Service policy, dated October 2024, documented that residents are provided meals that are prepared by methods that conserve value, flavor, and appearance. Residents are provided with food and drinks that are palatable, attractive, and at a safe and appetizing temperature. Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. The policy lacked definitive guidelines for the preparation of the pureed diets. The facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance while preparing a pureed diet. This placed the affected two residents at risk for impaired nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 6 when staff did not use the right type of slide board for R6, who had a previous staff-assisted fall using a slide board. The facility further failed to address the risk after a staff-assisted fall. The facility failed to ensure a safe environment free from accident hazards for R10, who had large openings in the side rails presenting a risk for entrapment. Additionally, the facility failed to ensure a safe environment for R47 who had medications stored on her bookshelf, and for R52 who did not wear a smoke apron as per her plan of care while smoking. These failures placed the affected residents at risk for preventable accidents and related injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting the left non-dominant side, muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), and obesity (excessive body fat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition and was dependent on staff for toileting, showers, lower body dressing, and transfers. R6 required substantial assistance from staff for mobility and upper body dressing. R6 had upper and lower functional impairment on one side, had one noninjury fall, and had not received therapy. The Fall Assessments, dated 10/02/24, 07/03/24, 04/03/24, and 01/02/24, documented R6 had a high risk for falls. R6's Care Plan, dated 08/29/24 and initiated on 10/22/15 documented R6 was at risk for falls related to a history of falls, hemiplegia to his left side, and generalized muscle weakness. The update, dated 11/22/23, directed staff to encourage exercise and mobility to maximize and maintain balance, strength, and coordination. Staff were to, answer his call light promptly, use a gait belt when assisting the resident with mobility, and make sure he wore appropriate shoes or nonslip socks when not in bed and during all transfers. The care plan directed staff to monitor for any changes in his mental, emotional, or physical condition. The update dated 05/29/24, directed staff to transfer R6 with two staff and to use the Beasy transfer board (a portable slide board transfer system that has a circular seat that rotates 360 degrees to easily turn to the exact angle, allowing the smallest caregiver ability to transfer someone up to 400 pounds (lbs) using a smooth lateral glide), gait belt, and have his right leg leading. The care plan documented that if the nurse determined R6 was too weak to transfer with the Beasy board, use a Hoyer (full mechanical body lift) and two staff for transfers. The Fall Investigation, dated 10/22/24, documented R6 was on the floor beside his bed, propped up with his right arm. Certified Nurse Aide (CNA) M reported that while in the room, she performed a two-person transfer, using a gait belt and slide board. R6 became weak, so the CNA lowered him to the floor. R6 stated he became weak, his legs went out, and staff slid him down to the floor. R6 did not sustain an injury, had on proper footwear, and denied any pain. The investigation documented the care plan was followed. The investigation documented a statement from CNA M was obtained, and the Director of Nursing (DON) educated the CNA that if R6 experienced weakness, staff were to use the Hoyer lift for transfers. On 11/19/24 at 01:10 PM, observation revealed CNA M and CNA O tried to find a gait belt that fit appropriately around R6's waist. CNA M stated she had used a gait belt around his waist earlier but put it in the laundry so now they had to find one to fit him. CNA M and CNA O both tried three different gait belts on R6 but they were all too short, so CNA O left and found one that was appropriate for R6's size. CNA M lowered R6's bed, placed the wheelchair flush with the side of the bed, and removed the right armrest from the wheelchair. CNA M took the flat, wooden slide board that lacked a circular seat that rotated and attempted to place it under R6's right buttocks (the round fleshy part that forms the lower rear area of a human trunk) but it did not slide under him easily. CNA M grabbed the gait belt to assist R6 in lifting his right buttock and it took CNA O to assist CNA M with lifting. The CNA was then able to quickly slide the wooden transfer board under R6's right side. Continued observation revealed the weight of the resident on the slide board caused it to lift off of the bed on one end, and CNA O stated that staff had to use two hands on it to hold it down so the resident could slide over. CNA O held down the slide board and CNA M assisted R6 to slide over onto the bed. R6's feet were placed on the bed, and he was provided his call light. On 11/19/24 at 01:30 PM, CNA O stated she was the restorative aide who worked all over the building. CNA O said if a resident required the use of a lift or slide board, therapy would train staff on how to do it. CNA O stated she was unaware of any falls related to the slide board for R6. On 11/19/24 at 01:35 PM, CNA M stated staff follow the pocket care plan that tells them how a resident was transferred. When asked if she was aware of any falls for R6, CNA M answered by asking Are you aware of any falls? She then stated she was unaware of any falls with R6 and the slide board. On 11/19/24 at 01:40 PM, Administrative Nurse D stated she would contact therapy to see if R6 needed to be evaluated to make sure the slide board was still appropriate for him. Administrative Nurse D stated R6 was a big man and that the description of the transfer with the slide board did not sound like the transfer was done correctly. On 11/19/24 at 02:00 PM, Licensed Nurse (LN) G stated if R6 was weak, staff were to use the Hoyer lift to transfer him. LN G said there was an occurrence when R6 was weak during a transfer and staff had to lower him to the ground. On 11/19/24 at 02:15 PM, Consultant HH stated R6 was last evaluated in February of 2024 for the use of the slide board and stated staff were trained on how to use it at that time. Consultant HH further stated that any new CNAs would be trained by the other CNAs on how to use the slide board with R6. On 11/19/24 at 4:40 PM, CNA M stated she was the CNA with R6 when he was lowered to the ground. CNA M stated she had a gait belt around him, and she and another CNA started to transfer him with the slide board but he said he was weak and would not make it, so she lowered him to the ground. CNA M explained that R6 did not stand well, his legs were weak and that he was too far past the wheelchair to be placed back in the chair, so she lowered him to the floor instead. CNA M further stated she couldn't get R6 to the bed or back to the wheelchair before she had to lower him to the floor. CNA M stated she had to watch computer training on transfers and had to demonstrate a transfer to the Director of Nursing, On 10/20/24 at 10:15 AM, CNA N stated when staff transferred R6, there had to be two CNAs and a gait belt because both staff must have their hands on the gait belt to help transfer R6 with the slide board. CNA N stated that R6 was slow-moving and that if he was ever weak, there was time to let him sit for a little bit before they tried to move him. CNA N stated that R6 liked to try to put the slide board under himself, but he did not do it correctly. On 11/20/24 at 01:00 PM, Administrative Nurse D stated she did not watch CNA M transfer R6 with the slide board but had CNA M tell her how R6 was transferred; she watched CNA M do transfers with other residents. Administrative Nurse D stated she did not get a statement from the second CNA nor could she remember who the second CNA was, therefore that second CNA was not provided with reeducation on transfers with slide boards. Administrative Nurse D could not explain what the second CNA was doing while CNA M was trying to transfer R6. The facility's Safe Lifting and Movement of Residents policy, dated 10/24, documented to protect the safety and well-being of staff and residents, and to promote quality, this facility used appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care would be trained in the use of manual (gait/transfer belt, lateral boards) and mechanical lifting devices. Staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. The facility's Falls and Fall Risk, Managing policy, dated 04/24, documented that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The interdisciplinary team would attempt to identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. The facility failed to ensure a safe environment free from accident hazards for R6 when staff did not use the right type of slide board. The facility further failed to address the risk after a staff-assisted fall. This placed R6 at risk for falls and fall-related injuries. - The Electronic Medical Record (EMR) for R10 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R10 had severely impaired cognition and had inattention and disorganized thinking daily. R10 was dependent on staff for toileting, mobility, and transfers. R10 had lower-body impairment on one side. And the MDS documented that R10 used side rails. R10's Side Rail Assessments, dated 09/09/24, 06/06/24, 03/09/24, and 12/09/23, documented no alternative to bed rails was attempted as she used the rails to pull or push for mobility; no alternatives were attempted, and failed; negative physical outcomes were discussed with R10's representative, and the care plan was updated. The assessments noted that R10's family demanded the side rails despite the risks. R10's Care Plan, dated 08/17/24 and initiated on 02/21/24, documented R10 had a hospital bed with quarter-rails up for safety during care and to assist with bed mobility. The plan directed staff to observe for injury or entrapment (being caught in or as in a trap) related to side rail use and reposition as needed to avoid injury. The update, dated 08/19/24, documented R10 used side rails to assist in entering and exiting the bed safely, moving up and down in bed, turning side to side, and pulling herself from a lying position to a sitting position. The care plan documented that side rail precautions were discussed and consent from the family had been obtained. The Physician's Order, dated 06/06/23, ordered a hospital bed with quarter-rails per Durable Power of Attorney (DPOA) preference. The facility's Risk versus Benefits dated 09/07/23, documented the form was for two side rails on R10's bed, and the form documented that if it were signed, the responsible party assumed full responsibility for all possible risks associated with not complying with the recommendations of the skilled professionals of the facility. The form further documented there were other risks from the decision to not comply with the mentioned treatment or recommendations, up to and including death: loss of dignity, pain, serious injury, loss of movement or function, abnormal movements, hospitalization, serious skin problems, falls, broken bones, and possible entrapment of head or body in the side rails. The form indicated that the DPOA signature on the risk versus the non-compliance was clearly explained to them and that they comprehended everything. The form lacked a signature from the resident or responsible party but documented the facility had spoken to the responsible party and the physician via phone. The form was signed by Administrative Nurse D and Administrative Nurse E. On 11/19/24 at 08:00 AM, observation revealed R10's bed with quarter-rails on both sides. Both rails had an opening approximately 18 inches by 15 inches. Continued observation revealed the bed rail was attached to the bed frame. On 11/19/24 at 09:15 AM, Administrative Nurse D stated she was aware the side rail opening was large and R10 was at risk for entrapment but she was unable to change the family's mind so they thought if they assessed and had it on the care plan, that it was ok. Administrative Nurse D stated that R10 originally had the halo transfer bars but the family wanted the quarter rails. The facility's Use of Physical Restraints, Including Bedrails policy, dated 08/24, documented restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should only be used to treat the resident's symptoms and never for discipline or staff convenience, or for the prevention of falls. Examples of devices that are/may be considered physical restraints include: using bedrails that keep the resident from voluntarily getting out of bed safely due to their physical or cognitive inability to lower the bed rail independently. Before placing a resident in restraints, there should be a pre-restraint assessment and review to determine the need for restraints, The assessment should be used to determine if there are fewer restricted interventions. Restraints should only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, the order alone was not sufficient to use the restraint. The order shall include the specific reason for the restraint, how the restraint would be used to benefit the resident's medical symptoms, the type of restraint, and the period for the use of the restraint. Restrained residents should be reviewed at least quarterly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. The care plan should include the measures taken to systematically reduce or eliminate the need for restraint use, and interventions that address not only the immediate medical symptom but the underlying problems that may cause the symptoms. Bed rail use would be based on resident preference and medical symptoms. The facility failed to ensure R10 a safe environment free from entrapment risks related to unsafe openings in R10's quarter-rails used on her bed. This placed R10 at risk for entrapment and related complications. - R47's Electronic Medical Record (EMR) documented R47 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R47's Quarterly Minimum Data Assessment, (MDS) revised 10/31/24, documented R47 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. R47's Care Plan revised 10/31/24, instructed staff to cue and reorientate R47 as needed, discuss with the resident, and administer medications as ordered. On 11/18/24 at 09:48 AM, observation in R47's room revealed the resident had a 32-ounce (oz) bottle of hydrogen peroxide (a liquid chemical used to make hair very pale or to kill bacteria) a two oz bottle of Dermagel psoriasis shampoo (medicated shampoo used to help reduce the itching, scaling, swelling, and skin discoloration) and a two oz bottle of fungiCURE intensive spray (a medication used to treat fungal infection disease caused by a fungus, such as yeast or mold) on a shelf in an open wooden bookshelf, visible from her entrance door. Further observation revealed the bottle of hydrogen peroxide label read may cause fire or explosion, harmful if swallowed, causes severe skin burns and eye damage, and harmful if inhaled. The Dermagel psoriasis shampoo label read for external use only, avoid contact with eyes and keep out of reach of children. The fungiCURE intensive spray box directed it was for external use only and to keep out of reach of children. On 11/18/24 at 10:26 AM, Administrative Nurse D verified the above finding and stated the items should not be in R47's room they should be locked in the medication cart. Administrative Nurse D took the items to the medication cart and asked the medication aide to lock them up in the cart. Upon request, the facility failed to provide a policy regarding accidents. The facility failed to ensure a safe environment free from accident hazards for R47. This placed the resident at risk for injury and preventable accidents. - The Electronic Medical Record (EMR) for R52 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness and difficulty walking. The Annual Minimum Data Set (MDS), dated [DATE], documented R52 had intact cognition and required partial to moderate assistance from staff for transfers and toileting. The MDS documented the resident required a walker or wheelchair for mobility. The Smoking Evaluation, dated 11/18/24, documented R52 had no cognitive loss, could not light her cigarettes, and required staff supervision. R52's Care Plan, dated 09/19/24, documented R52 was at risk for potential injury related to smoking. The care plan documented the resident required a smoking apron while smoking and could only go outside during supervised smoking breaks. On 11/19/24 at 08:50 AM, observation revealed R52 sat in a wheelchair at the back smoking patio door. She wheeled over to the nurse's cart and received two cigarettes from the staff then wheeled herself outside and sat on the patio and smoked two cigarettes along with eight other residents. Observation revealed the resident did not wear a smoking apron. On 11/20/24 at 10:40 AM, Administrative Nurse E verified R52's Care Plan which documented the resident required a smoking apron and stated the resident would not wear it and would probably refuse. Administrative Nurse E verified the employee who entered the information in the care plan worked for the facility one day a week from home. Administrative Nurse E said R52's plan of care should not have stated the resident required a smoking apron. The facility's Smoking policy, dated October 2024, documented residents are to smoke in designated smoking areas and are not allowed to keep smoking material in their personal possession. The facility is not responsible for providing smoking materials for the residents, including but not limited to lighters. All smoking materials are to be given to facility staff. The resident would receive two cigarettes at a time and would return the lighter to the charge nurse when finished smoking. The policy documented the resident would wear a smoking apron while smoking and would put their cigarette butt in the butt can. The facility failed to provide R52 with a smoking apron per her plan of care. This placed the resident at risk for accidents and injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 63 residents with 16 residents sampled, including one resident reviewed for admission, transfer, and discharge. Based on observation, interview and record review, the facility failed to notify in writing one Resident (R)116 and their representative of the intention to involuntarily discharge the resident from the facility, 30 days before the date of discharge. Findings included: - Review of Resident (R)116's electronic medical record (EMR) revealed a diagnosis of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. There was no active discharge planning for the resident to return to the community. The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA), dated 03/22/22, documented the resident required extensive to total assistance of staff for ADLs. The discharge MDS, dated 11/06/22, documented the resident discharged to an acute hospital and her return was anticipated. The care plan for discharge, revised, 10/05/22, instructed staff the resident had chosen to make the facility her home for long-term care. On 01/19/23 at 08:03 AM, Administrative Nurse D stated the facility did discharge the resident involuntarily from the facility without a 30-day notice. The facility felt that the resident required more care than the facility could provide. The resident admitted to the hospital on [DATE] and the facility notified the hospital on [DATE] that they would not accept the resident back to the facility upon discharge from the hospital. The facility lacked a policy for Admission, Transfer and Discharge. The facility failed to provide a 30-day notice for the involuntary discharge of this resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 63 residents with 16 residents sampled, including six residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to complete appropriate personal hygiene for one dependent Resident (R)11, regarding long, jagged, dirty fingernails and failed to complete appropriate oral care for dependent resident R117. Findings included: - Review of Resident (R)11's electronic medical record (EMR), revealed diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. He required extensive assistance of two staff for personal hygiene. Bathing did not occur during the assessment period. Review of the Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/06/22, did not trigger for further review. The quarterly MDS, dated 12/15/22, documented the staff assessment for cognition revealed severe impairment. He required extensive assistance of two staff for personal hygiene. He required physical help from one staff for bathing. The ADL care plan, revised 11/15/22, instructed staff the resident required total assistance of two staff for bathing, two times per week and required one staff assistance with personal hygiene. On 01/17/23 at 01:17 PM, the resident rested in bed. He had long, jagged, dirty fingernails. On 01/18/23 at 06:48 AM, the resident continued to have long, jagged, dirty fingernails. On 01/18/23 at 02:02 PM, the resident sat in his wheelchair in the front commons area following his shower. The resident continued to have long, jagged, dirty fingernails. On 01/18/23 at 07:30 AM, Certified Medication Aide (CMA) R stated staff were to cut and clean resident's fingernails on their shower days. On 01/19/23 at 08:30 AM, Certified Nurse Aide (CNA) M stated staff were to care for resident's fingernails on shower days and as needed (PRN). On 01/18/23 at 01:30 PM, Licensed Nurse (LN) H stated the CNAs would clean and file resident's fingernails on shower days. LN H confirmed the resident's fingernails were long, jagged, and dirty. On 01/19/23 at 01:08 PM, Administrative Nurse D stated residents should have their fingernails cleaned whenever they were visibly dirty. The facility policy for Activities of Daily Living, revised 2023, included: Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good grooming and personal hygiene. The facility failed to clean and file the fingernails of this dependent resident. - Review of Resident (R)117's electronic medical record (EMR), revealed diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. She required extensive assistance of one staff for personal hygiene. The bathing did not occur during the assessment period. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/07/22, documented the resident required extensive to total assistance with ADLs. The ADL care plan, dated 01/17/23, instructed staff to perform oral care every two hours. On 01/17/23 at 02:00 PM, Certified Nurse Aide (CNA) N and O took the resident to her room to lie down. The resident had a thick covering of a black debris on her bottom teeth and tongue as well as in between her top teeth. Staff situated the resident in bed and left the room. Staff did not perform oral care during the cares. On 01/17/23 at 04:03 PM, the resident rested in bed. She continued to have a thick layer off black debris covering her bottom teeth, tongue, bottom lip and in between her upper teeth. On 01/18/23 at 08:15 AM, the resident rested on her back in bed. The resident's mouth continued to have a thick layer of black debris. On 01/18/23 at 09:49 AM, CNA P propelled the resident in her wheelchair. The resident's mouth continued to have a thick layer of black debris. On 01/17/23 at 02:00 PM, CNA O stated staff did oral care with the resident whenever cares were given. On 01/17/23 at 02:00 PM, CNA N stated she did not know why the resident had so much black debris in her mouth. On 01/18/23 at 09:49 AM, CNA P stated the black debris in the resident's mouth was dried blood from a sore on her bottom lip. Staff were to clean the resident's mouth with lemon swabs, as needed (PRN). On 01/18/23 at 03:52 PM, Licensed Nurse (LN) I stated the resident has tremors and bites the inside of her cheek and her tongue. This was what was causing the resident's mouth to bleed which was causing the black debris in her mouth. Staff were to do oral care, PRN. On 01/19/23 at 01:08 PM, Administrative Nurse D stated the staff were to be doing oral care several times throughout the day. The facility policy for Activities of Daily Living, revised 2023, included: Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good grooming and personal hygiene. The facility failed to perform oral care for this dependent resident to ensure good oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 63 residents, with two residents reviewed for the care of a gastrostomy tube (G-tube) (a tube that is placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications, also called a PEG tube, percutaneous endoscopic tube.). Based on observations, interviews, and record review, the facility failed to provide appropriate and sufficient services, treatment, and care based upon current standards of practice to ensure that Resident (R) 13 received proper treatment and services to prevent infection of the stoma (surgically created opening of an internal organ on the surface of the body) where the G-tube inserted through the skin. Findings included: - Resident (R) 13's pertinent diagnoses from the 12/11/22 Physician Order Sheet included: dysphagia (swallowing difficulty) following other cerebrovascular diseases (group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain). The quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had a brief interview for mental status score (BIMS) of 0, indicating cognitive impairment. The resident required extensive assistance, two plus person physical assistance for all activities of daily living (ADLs). The resident had an abdominal (PEG) feeding tube and took nothing by mouth. The resident was dependent on caregivers to use a manual wheelchair. The Feeding Tube Care Area Assessment, dated 09/23/22, revealed the resident was fed via a PEG tube. Risk factors include weight instability, impaired fluid balance, abnormal lab values, and impaired skin integrity. The Care Plan for diet, dated 12/27/22, documented the resident had a feeding tube and was at risk for fluid balance fluctuation, alteration in nutrition, and weight loss. In addition, it revealed the PEG tube dressing was to be changed daily. A review of the Physicians Orders dated 07/11/22 revealed the resident's PEG tube site was to be cleansed with wound cleanser, dried, and a split gauze was to be applied to the PEG tube site twice a day and as needed for drainage or saturation. On 01/18/23 at 10:13 AM, the resident was lying in his bed. His stoma site was crusty and red. The resident flinched when staff lifted his gown, and the PEG tube moved slightly. On 01/18/23 at 10:53 AM, Licensed Nurse G performed the PEG tube care and split gauze change. She donned a gown and gloves. It was observed that she pushed aside the resident's belongings and dressing supplies on the resident's bedside table and did not clean the table's surface or put down a barrier. She pulled a stack of gauze pads from an open package and laid them directly on the bedside table. She removed the resident's split gauze dressing. The stoma was red and excoriated (part of the skin was worn off), and there was a small amount of bleeding on the old dressing. She then disposed of the old dressing in the trash can, used hand sanitizer, and put on a new pair of clean gloves. She took some of the gauze from the stack placed on the bedside table and sprayed it with a wound cleanser. Next, she used wet gauze to clean around the stoma site. She used all of the gauze she placed directly on the bedside table to wipe the stoma site, including the last piece, which was in direct contact with the table's soiled surface. She removed a clean split gauze from the package without hand hygiene or changing gloves. The clean split gauze was applied to the PEG tube site as ordered. The dressing lacked a date or initial. The nurse then removed her gown and gloves and used hand sanitizer. On 01/18/23 at 11:00 AM, Licensed Nurse G reported she did not need to clean the bedside table surface or place down a barrier because changing R 13's PEG dressing did not require a sterile technique; it was a clean procedure. She stated the redness and excoriation with bleeding at the resident's stoma was normal and she was not concerned about it. On 01/18/23 11:10 AM, Licensed Nurse H reported the resident's stoma was always red and excoriated with drainage, and his physician was aware. She reported the dressing change was to be done using the clean technique and the overbed table should be cleaned, or a barrier should be placed on the surface for placement of the clean supplies. The facility's policy for Gastrostomy/Jejunostomy Site Care, last revised 06/2021, documented to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown, and infection, equipment for site care should be placed on a clean over bed table. The facility failed to provide appropriate and sufficient care and treatment based upon current standards of practice to ensure that the resident received proper treatment and services to prevent infection of the stoma where the G-tube inserted through his skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 63 residents with 16 residents sampled, including three residents reviewed for respiratory. Based on observation, interview and record review, the facility failed to provide appropriate respiratory care for one Resident (R)117, of the three sampled, regarding oxygen tubing to prevent respiratory infections. Findings included: - Review of Resident (R)117's electronic medical record (EMR), revealed diagnoses of hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. She used oxygen while a resident at the facility. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/07/22, documented the resident required extensive to total assistance with ADLs. The care plan, dated 12/18/22, lacked staff instruction for care of the resident's oxygen usage. Review of the resident's EMR, revealed an order for oxygen (O2) at two liters (L) per minute (min) per nasal cannula (NC), to keep O2 saturation (sat) above 90%, ordered 12/02/22. On 01/07/23 at 02:00 PM, Certified Nurse Aide (CNA) N and O transferred the resident from her wheelchair to her bed following lunch. The oxygen tubing and NC laid directly on the floor next to the bed. After situating the resident in bed, CNA N picked up the tubing and NC from the floor and put it directly onto the resident. On 01/17/23 at 02:00 PM, CNA O stated the resident wore the oxygen all the time. On 01/17/23 at 02:00 PM, CNA N stated the oxygen tubing should be kept off the floor when not in use. The tubing and cannula should have been changed before putting it onto the resident due to the cannula having been on the floor. On 01/18/23 at 03:52 PM, Licensed Nurse (LN) I stated oxygen tubing would need to be changed if the nasal cannula was on the floor. On 01/19/23 at 01:08 PM, Administrative Nurse D stated she would expect staff to change the oxygen tubing and nasal cannula if it came into direct contact with the floor. The facility lacked a policy for the appropriate sanitary care of oxygen tubing. The facility failed to sanitize or replace this resident's oxygen tubing and nasal cannula after it rested directly on the floor and before reapplying it to the resident's nose to prevent respiratory infections.

The facility reported a census of 61 residents with 15 residents included in the sample. Based on observation, interview, and record review, the facility failed to promote dignity by the failure of staff to provide a privacy/dignity bag for an indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) collection bag for Resident (R) 40. Findings included: - Review of the Annual Minimal Data Set dated 05/10/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R40 required limited assistance with toileting of one staff person. Review of the Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/10/21 revealed R40 required limited assistance with toileting and had actual incontinent episodes. Review of the Care Plan dated 06/22/21 revealed R40 had an indwelling urinary catheter related to incontinence and needing accurate output. The Care Plan lacked mention of a dignity bag to cover the urinary catheter collection bag. Review of the Progress Note dated 06/25/21 at 06:42 PM revealed R40 with a urinary catheter in place. Observation on 07/01/21 at 07:55 AM revealed R40 laid in bed on her right side with an indwelling catheter collection bag hanging on the bed frame. Observation revealed no privacy bag covered the catheter collection bag, visible from the hallway by anyone who passed by. Observation of R40 on 07/01/21 at 03:45 PM revealed she ambulated in the hallway with the indwelling catheter collection bag hanging on the walker, and no privacy bag covered the collection bag. Interview with CNA J on 07/06/21 at 11:08 AM confirmed R40 did not have a privacy bag because it was a new catheter. Interview with Licensed Nurse (LN) C on 07/06/21 at 11:58 AM revealed the dignity bag/privacy bag was used to conceal the urine. Interview with Administrative Staff B on 07/07/21 08:31 AM revealed she expected the indwelling urinary catheter collection bag to be in a dignity bag at all times. The facility policy regarding Exercise of Rights/Resident Rights dated 05/21 revealed staff promoted dignity by helping residents keep their urinary catheter collection bags covered. The facility failed to promote dignity by not providing R40 with a privacy bag for an indwelling urinary catheter collection bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 61 residents with 15 included in the sample and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identify the lack of physician notifications for blood glucose (BG, sugar in the blood) levels which were outside of physician-ordered parameters of greater than 400 milligrams per deciliter (mg/dL) for Residents (R) 38 and if greater than 300 mg/dL for R2, both with diagnoses of diabetes mellitus (DM, when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). Findings included: - Review of R38's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented type two DM and dementia (progressive mental disorder characterized by failing memory, confusion). Review of the 02/15/21 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating severely impaired cognition. R38 had a diagnosis of DM and received daily insulin injections in the seven day look back period. The 05/17/21 Care Plan for R38 documented the resident with a diagnosis of DM. The Care Plan instructed staff to administer medications and monitor for side effects as ordered by the physician. Review of the Physicians Orders documented that R38 had an order on 07/29/20 for blood sugar levels to be obtained and staff were to call the physician if the results were less than 60 mg/dL or greater than 400 mg/dL. Review of the January through July 2021 Electronic Medication Administration Record (EMAR) documented the following six dates with elevated blood glucose levels outside of parameters and lacked evidence of physician notifications: 01/10/21 at 05:47 PM BG level of 471 mg/dL 03/10/21 at 11:56 AM BG level of 409 mg/dL 05/25/21 at 12:40 PM BG level of 471 mg/dL 06/16/21 at 09:56 AM BG level of 486 mg/dL 06/16/21 at 12:39 PM BG level of 440 mg/dL 06/21/21 at 01:15 PM BG level of 491 mg/dL Review of the Nursing Progress Notes from 01/21/21 through 06/21/21 lacked evidence of physician notification for the six out of parameter blood glucose readings as listed above. Review of the Pharmacy Medication Record Reviews (MRR) for January through July 2021 completed monthly, lacked identifying physician notifications of blood glucose out of physician ordered parameters. Observation on 07/01/21 at 08:17 AM revealed R38 as awake, alert, and eating the morning meal with no assistance. On 07/07/21 at 08:30 AM Administrative Nursing Staff B stated if a resident's blood glucose level fell outside of parameters, the nurse should notify the physician and document it in the nursing progress notes. Administrative Staff B stated she expected that the consultant pharmacist would inform the facility if the nursing staff were not notifying the physician for blood glucose levels outside of parameters. On 07/06/21 at 02:22 PM Consultant Staff O revealed that he would check blood glucose levels and notifications to provider and make recommendations but that he missed the blood glucose levels. The facility's Medication Regimen Reviews and Pharmacy Services Overview policies approved 05/2021 documented that the consultant pharmacist shall review the medication regimen and collaborate with the staff and practitioners to address and resolve medication-related needs or problems. The facility failed to have the pharmacist identify the lack of physician notifications for blood glucose out of physician-ordered parameters to keep this resident free from possible medication side effects. - Review of R2's signed Physician Orders dated 06/09/21 revealed a diagnosis of type 2 DM. Review of the admission Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident received daily insulin (hormone which regulates blood glucose) injections during the seven-day review period. Review of the Standing Orders dated 03/07/19 instructed staff to call the provider for blood glucose (BG) levels of Hyperglycemia (high blood sugar), greater than 300 mg/dL, unless otherwise specified. Review of the Electronic Medication Administration Record revealed the following elevated blood glucose levels of greater than 300 mg/dL and lacked notification to the provider. 01/03/21 at 09:23 PM BG level of 313 mg/dL 02/02/21 at 04:37 PM BG level of 349 mg/dl 03/01/21 at 12:10 PM BG level of 354 mg/dl 05/20/21 at 03:53 PM BG level of 325 mg/dL 06/02/21 at 08:41 AM BG level of 336 mg/dL 06/04/21 at 07:47 PM BG level of 320 mg/dL 06/05/21 at 07:37 PM BG level of 370 mg/dL 06/06/21 at 09:18 PM BG level of 470 mg/dL 06/07/21 at 07:10 PM BG level of 318 mg/dL 06/08/21 at 08:08 PM BG level of 345 mg/dL 06/09/21 at 07:17 PM BG level of 401 mg/dL 06/11/21 at 07:17 PM BG level of 334 mg/dL 06/12/21 at 04:30 PM BG level of 324 mg/dL 06/12/21 at 10:00 PM BG level of 334 mg/dL 06/13/21 at 07:34 PM BG level of 313 mg/dL 06/14/21 at 07:50 PM BG level of 334 mg/dL 06/15/21 at 08:08 PM BG level of 335 mg/dL 06/16/21 at 07:31 PM BG level of 350 mg/dL 06/17/21 at 07:45 PM BG level of 354 mg/dL 06/17/21 at 07:45 PM BG level of 354 mg/dL 06/17/21 at 10:22 PM BG level of 324 mg/dL 07/03/21 at 07:51 PM BG level of 356 mg/dL 07/03/21 at 07:51 PM BG level of 388 mg/dL Review of the Nursing Progress Notes from 01/03/21 through 07/03/21 lacked evidence of physician notification for the above listed elevated and out of parameter BG levels. Review of the Monthly Pharmacy Medication Review from 12/16/20 to 06/14/21 revealed the pharmacist failed to identify the lack of notifications for the elevated blood glucose levels, outside of standing order parameters, for R2. Interview on 07/06/21 at 12:01 PM with Licensed Nurse (LN) C revealed if the staff did not have a specific order to contact the provider, the staff used the standing orders to call the physician if the blood glucose level was less than 60 mg/dL or greater than 300 mg/dL. LN C stated the staff documented this in either the Medication Administration Record or the Progress Notes. Interview on 07/06/21 at 02:22 PM with Consultant Pharmacist O revealed he reviewed the blood glucose levels and parameter's and made recommendations, according to the standing orders of the provider. Consultant Pharmacist O stated he missed the blood glucose levels in R2's chart. Review of the policy Pharmacy Services dated 05/2021 revealed a licensed pharmacist helped obtain and maintain timely and appropriate pharmacy services that supported residents' needs, consistent with current standards of practice, and met state and federal requirements. The facility failed to ensure the consultant pharmacist identified the lack of physician notifications for the 23 elevated and out of standing order parameter, blood glucose levels (greater than 300 mg/dL) for R2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 61 residents with 15 included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to notify the physician of blood glucose (BG, sugar in the blood) levels which were outside of physician-ordered parameters of greater than 400 milligrams per deciliter (mg/dL) for Resident (R) 38 and if greater than 300 mg/dL for R2, to ensure appropriate monitoring and efficacy in the medication management of their diabetes mellitus (DM, when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), . Findings included: - Review of R38's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 05/03/21 documented type two DM and dementia (progressive mental disorder characterized by failing memory, confusion). Review of the 02/15/21 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. R38 had a diagnosis of DM and received daily insulin injections in the seven day look back period. The 05/17/21 Care Plan for R38 documented the resident with a diagnosis of DM. The Care Plan instructed staff to administer medications and monitor for side effects as ordered by the physician. Review of the Physicians Orders documented that R38 had an order on 07/29/20 for blood sugar levels to be obtained and staff were to call the physician if the results were less than 60 mg/dL or greater than 400 mg/dL. Review of the January through July 2021 Electronic Medication Administration Record (EMAR) documented the following six dates with elevated blood glucose levels outside of parameters and lacked evidence of physician notifications: 01/10/21 at 05:47 PM BG level of 471 mg/dL 03/10/21 at 11:56 AM BG level of 409 mg/dL 05/25/21 at 12:40 PM BG level of 471 mg/dL 06/16/21 at 09:56 AM BG level of 486 mg/dL 06/16/21 at 12:39 PM BG level of 440 mg/dL 06/21/21 at 01:15 PM BG level of 491 mg/dL Review of the Nursing Progress Notes from 01/21/21 through 06/21/21 lacked evidence of physician notification for the six out of parameter blood glucose readings as listed above. On 07/01/21 at 07:11 AM Licensed Nurse (LN) N revealed for R38 the staff had orders to call the physician if the blood glucose levels were less than 60 mg/dL or greater than 400 mg/dL. LN N stated if the blood glucose levels were outside of the parameters, the staff should call the residents doctor for further instructions or new orders, and the LN should document the notification in the resident's medical record. Observation on 07/01/21 at 08:17 AM revealed R38 was awake, alert, and eating the morning meal with no assistance. On 07/07/21 at 08:30 AM Administrative Nursing Staff B stated if a resident's blood glucose level fell outside of parameters, the nurse should notify the physician and document it in the nursing progress notes. The facility's Guidelines for Notifying Physicians of Clinical Problems policy approved on 05/2021 documented the guidelines were to help ensure that medical care problems were communicated to the medical staff in a timely, efficient and effective manner. The facility failed to notify the physician of elevated blood sugars outside of physician-ordered parameters to ensure appropriate monitoring and efficacy in their DM medication management. - Review of R2's signed Physician Orders dated 06/09/21 revealed a diagnosis of Type 2 DM. Review of the admission Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The resident received daily insulin (hormone which regulates blood glucose) injections during the seven-day review period. Review of the Care Plan dated 05/22/18 revealed R2 required diabetes medication to be administered as ordered by the physician and the staff were to monitor for side effects. Review of the Standing Orders dated 03/07/19 regarding blood glucose (BG) levels for Hyperglycemia (high blood sugar), revealed the staff were to call the provider for BG levels of greater than 300 milligrams per deciliter (mg/dL), unless otherwise specified. Review of the Electronic Medication Administration Record revealed the following 23 elevated blood glucose levels of greater than 300 mg/dL and lacked notification to the provider: 01/03/21 at 09:23 PM BG level of 313 mg/dL 02/02/21 at 04:37 PM BG level of 349 mg/dl 03/01/21 at 12:10 PM BG level of 354 mg/dl 05/20/21 at 03:53 PM BG level of 325 mg/dL 06/02/21 at 08:41 AM BG level of 336 mg/dL 06/04/21 at 07:47 PM BG level of 320 mg/dL 06/05/21 at 07:37 PM BG level of 370 mg/dL 06/06/21 at 09:18 PM BG level of 470 mg/dL 06/07/21 at 07:10 PM BG level of 318 mg/dL 06/08/21 at 08:08 PM BG level of 345 mg/dL 06/09/21 at 07:17 PM BG level of 401 mg/dL 06/11/21 at 07:17 PM BG level of 334 mg/dL 06/12/21 at 04:30 PM BG level of 324 mg/dL 06/12/21 at 10:00 PM BG level of 334 mg/dL 06/13/21 at 07:34 PM BG level of 313 mg/dL 06/14/21 at 07:50 PM BG level of 334 mg/dL 06/15/21 at 08:08 PM BG level of 335 mg/dL 06/16/21 at 07:31 PM BG level of 350 mg/dL 06/17/21 at 07:45 PM BG level of 354 mg/dL 06/17/21 at 07:45 PM BG level of 354 mg/dL 06/17/21 at 10:22 PM BG level of 324 mg/dL 07/03/21 at 07:51 PM BG level of 356 mg/dL 07/03/21 at 07:51 PM BG level of 388 mg/dL Review of the Nursing Progress Notes from 01/03/21 through 07/03/21 lacked evidence of physician notification for the above listed elevated and out of parameter BG levels. Interview on 07/06/21 at 12:01 PM with Licensed Nurse (LN) C revealed if the staff did not have a specific order to contact the provider, the staff used the standing orders to call the physician if the blood glucose level were less than 60 mg/dL or greater than 300 mg/dL. LN C stated the staff documented this in either the Medication Administration Record or the Progress Notes. Interview on 07/06/21 at 04:38 PM with Administrative Nurse B revealed She expected the nursing staff to contact the physician for blood glucose levels of less than 60 mg/dL or greater than 300 mg/dL. The policy Guidelines for Notifying Physicians of Clinical Problems Nursing observations that might require physician action; for example, significant fluctuations in blood sugar such as changes in a normally well-controlled diabetic The facility failed to ensure appropriate monitoring and efficacy of DM medication management when staff failed to notify the physician of 23 elevated and out of standing order parameter blood glucose levels (greater than 300 mg/dL) for R2.

The facility census totaled 61 residents, with two hallways being affected serving 26 residents. Based on observation, interview, and record review, the facility failed to ensure housekeeping staff followed the manufacturer's recommendations to ensure the effective wet time for the cleaning solution, resulting in inadequate cleaning and the potential for infection. Findings included: - Observation of cleaning a room by Housekeeping Staff I on the 300 hall on 07/06/21 at 01:45 PM revealed she sprayed the peroxide multi-surface cleaner on the sink and counter and one minute later, at 01:46 PM, she proceeded to wipe off the cleaner with a cloth. Per the peroxide multi-surface cleaner manufacturer data, the solution would achieve hospital-level disinfection with a wet time of three to five minutes. The facility lacked documentation of training on the peroxide multi-surface cleaner since the facility began using the solution on 06/15/21. Interview with Housekeeping Staff I on 07/06/21 at 01:30 PM revealed she was responsible for cleaning the rooms on the 300 and 400 hallways. She said she utilized the peroxide multi-surface cleaner, which was new to her since they just got the chemical last month and reported not having any training over the use of the cleanser. Additionally, she reported she did not know how long the chemical needed to sit wet, as it was a new product, but believed around 15 minutes. Housekeeping Staff I said she had a few Carbapenem-resistant Acinetobacter baumannii (CRAB, an opportunistic pathogen infection-causing organism primarily associated with hospital-acquired infections resistant to many antibiotics) rooms she cleans on the 300 hall, and she cleaned those rooms last. She stated she used the same peroxide multi-surface cleaner to clean those rooms, too. Interview with Environmental Services Manager (ESM) L on 07/06/21 at 01:53 PM revealed she did not know about the wet time for the peroxide cleaner and confirmed no housekeeping training on the use of the cleaner since she started on 06/15/21. ESM L said the staff were expected to use a bleach solution to clean rooms with CRAB. Interview with Administrative Nursing Staff H on 06/30/21 at 01:21 PM revealed the facility completed random weekly audits for infection control and had not found any concerns with cleaning of the rooms. A review of the undated Healthcare Services Group, Inc. Job Description revealed staff were responsible for the safe and proper use of cleaning solutions. The facility failed to ensure housekeeping staff followed the manufacturer's recommendations to ensure the effective wet time for the cleaning solution utilized in resident room cleaning.