Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to maintain an effective call system to allow residents to call for staff assistance. During an observation of the main shower room on 04/09/2024 at 8:50 AM, revealed the emergency pull cord call light was not functioning. The findings include: Review of the facility's policy titled, Maintenance Services, revised December 2009, revealed maintenance service should be provided to all areas of the building, grounds, and equipment. Review of the facility's policy titled, Answering the Call Light, revised September 2022, revealed the procedure was to ensure timely responses to the resident's requests and needs. The policy listed the following general guidelines: staff should ensure the call light was plugged in and functioning at all times, accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor, and report all defective call lights to the nurse supervisor promptly. Observation on 04/09/2024 at 8:50 AM, revealed the emergency pull cord in the main shower room was not functioning. the Assistant Director of Nursing (ADON) became aware that the facility's call system was not properly operating in the main shower room. The ADON immediately notified the maintenance director to initiate repair of the call system. Observation on 04/09/2024 at 1:31 PM, revealed call lights were not functioning in rooms 101-A and 103-A. Further observation revealed the call light pull cords in the bathrooms 101-A, 102, 106, and 340 were not functioning. During an interview with the Assistant Director of Nursing (ADON) on 04/09/2024 at 8:50 AM, she stated she was not aware the call light pull cord in the main shower room was not functioning and no one had reported it to her. The ADON further stated she did not know if maintenance was aware of the issue. She stated resident's were never left alone in the shower room but if staff needed assistance, they would not be able to pull the cord to alert someone they needed help and would have to open the door and yell for help. During an interview with the former Maintenance Director on 04/09/2024 at 12:54 PM, he stated the majority of the call lights and pull cords in the resident's rooms did not work when he worked at the facility. He stated obtaining supplies was difficult due to the facility having outstanding invoices with local supply companies. The former Maintenance Director further stated the call light was a resident's life line and if it was not functioning, they could not notify staff they needed assistance. During an interview with the Maintenance Director on 04/09/2024 at 1:31 PM, he stated he was responsible to ensure the facility had a functioning call system. He stated the ADON notified him this morning of the pull cord in the main shower room not functioning and he replaced the switch. The Maintenance Director stated he had not been made aware of any call lights or pull cords not functioning properly prior to today. He stated he does rounds every day and inspects the rooms and would repair or replace the call lights or pull cords at that time. The Maintenance Director stated if the call system was not working, a resident could not call for help if needed. During an interview with State Registered Nursing Assistant (SRNA) #1 on 04/10/2024 at 1:49 PM, she stated some of the bathroom call lights had not been working but she could not remember which rooms. SRNA #1 also stated on Sunday a call light on the 200 hall would work but the light was not working at the end of the hall. She further stated the main shower room didn't even have a string for the pull cord. SRNA #1 stated if she needed help she would have to open the door and yell for help. During an interview with the Director of Nursing (DON) on 04/11/2024 at 3:16 PM, she stated she was unaware of any call lights not working. She stated she expected the call system to function properly or a need could go unmet. During an interview with the Administrator on 04/11/2024 at 3:29 PM, she stated call lights were very important. She stated if there was a concern with call lights not functioning, she expected maintenance to bring it up during morning stand up meetings and to fix it immediately. The administrator stated she expected the call system to work properly.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in an environment that promotes maintenance or enhancement of his or her quality of life for two (2) of seventeen (17) sampled residents (Residents #23 and #44). Observation on 04/02/19, revealed Resident #23 and #44 were not being assisted with their lunch meal, while other residents at the table were being assisted and eating. The findings include: Review of the facility policy titled, Meal Service in Dining Room, last revised 01/02/14, revealed staff should serve all patients at a table at the same time. If a patient requires assistance with eating, do not serve trays to the table until assistance is available. 1. Record review revealed the facility admitted Resident #23 on with diagnoses, which included. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/18/19 , revealed the facility assessed Resident #23's cognition as severely impaired as he/she was unable to complete the Brief Interview of Mental Status (BIMS), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident required total assistance of one (1) or two (2) staff to eat. Observation on 04/02/19 at 11:49 AM, in the Main Dining area, revealed Resident #23 was sitting in a broda chair with his/her meal tray in front of him/her. Further observation revealed Licensed Practical Nurse (LPN) #2 was feeding one (1) resident, and a another resident was feeding him/herself. Continued observation revealed LPN #2 did not attempt to assist Resident #23 until 12:21 PM and surveyor brought the lapsed time to her attention. LPN #2 retrieved a new tray from the kitchen for Resident #23. Interview with LPN #2 on 04/02/19 at 12:33 AM, revealed she feeds only one (1) resident at a time and she had planned on assisting Resident #23 when the other resident was done with his/her meal. She stated the resident was nodding off and she had not realized over thirty (30) minutes had gone by. 2. Record review revealed the facility admitted Resident #44 on 09/08/17 with diagnoses which included Muscle Weakness (generalized), Unspecified Lack of Coordination, and Alzheimer's Disease, Unspecified. Review of the Quarterly MDS Assessment, dated 03/13/19, revealed the facility assessed the Resident #44's cognition as severely impaired with a BIMS score of zero (0) as he/she was unable to complete the assessment which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total assistance of one (1) staff to eat. Observation on 04/02/19 at 11:55 AM revealed Resident #44 in a broda chair sitting at a dining room table with a covered plate on the table in front of him/her. There were three (3) additional residents at the same table, two (2) were receiving feeding assistance from Certified Nurse Aide (CNA) #1 and the other resident was feeding him/herself with assistance from a family member. No one was assisting Resident #44. Additional observation revealed CNA #1 was having a personal conversation with a family member, also seated at the table, and not engaging the residents in conversation. Further observation on 04/02/19 at 12:20 PM revealed Resident #44's covered plate remained on the table in front of her. LPN #1 removed the resident's plate and took it to the kitchen. At 12:27 PM, LPN #1 returned to Resident #44's table with a plate, retrieved a chair, and sat down beside the resident and began feeding him/her lunch, thirty-two (32) minutes after the original plate was served and the other residents at the table had began eating. Interview with CNA #1 on 04/02/19 at 12:03 PM revealed no one is feeding Resident #44 because there are not enough staff to help. CNA #1 stated this is not an every day occurrence, but today has been a crazy day and there was a call in today. Interview with CNA #3, on 04/05/19 at 11:08 AM, revealed she can feed two (2) residents at a time as long as she does not cross contaminate anything. She stated Resident #23 can be lethargic during meals and was a total feed. CNA #3 further revealed all residents should be served and assisted with meals at the same time. She stated staff completed training's online about resident rights and dignity upon hire and quarterly. Interview with the Director of Nursing (DON), on 04/05/19 at 10:22 AM, revealed there was no specific policy regarding the amount of residents staff can feed a the same time, but she would expect staff to assist the residents in a timely manner at the same table. She stated staff can sit between two (2) residents and assist both at the same time, as long as they ensure there is no cross contamination. The DON further revealed all staff was checked off on certain skills and received training on resident rights and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 Users Manual Version 1.16, October, 2018, it was determined the facility failed to ensure three (3) of seventeen (17) sampled residents received an accurate assessment, reflective of the resident's status (Residents #37, #47, and #51). Residents #47 and Resident #51 were taking anti-coagulant medications, however, the residents' Minimum Data Set (MDS) assessments indicated the residents were not on anti-coagulants. In addition, Resident #37 fell on [DATE], however, the fall was not reflected on the resident's 03/25/29 Quarterly MDS Assessment. The findings include: Interview with the MDS Coordinator on 04/05/19 at 8:52 AM revealed the RAI Users Manual is used for reference when completing MDS Assessments. Review of the RAI 3.0 Users Manual, Version 1.16, October, 2018, Section N0401, Medications Received, revealed the intent of the items in this section is to record the number of days, during the last seven (7) days that any type of injection, insulin, and/or select medications were received by the resident. Medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes, such as curing an illness, diagnosing a disease or condition, arresting or slowing a disease's progress, reducing or eliminating symptoms, or preventing a disease or symptom. Residents taking medications in these medication categories and pharmacologic classes are at risk of side effects that can adversely affect health, safety, and quality of life. Review the resident's medical record for documentation that any of these medications were received by the resident during the seven (7)-day look-back period. Section N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the seven (7)-day look-back period. Include any of these medications given to the resident by any route (e.g., PO, IM, or IV) in any setting (e.g., at the nursing home, in a hospital emergency room) while a resident of the nursing home. Code a medication even if it was given only once during the look-back period. 1. Record review revealed the facility admitted Resident #47 on 01/14/19 with diagnoses which included Unspecified Sequelae of Cerebral Infarction and Unspecified Atrial Fibrillation. Review of Resident #47's Physician's Order Sheet for April 2019, revealed an order that was initiated on 01/14/19 for Apixaban (Eliquis, an anti-coagulant) tablet 5 milligrams (mg), give one (1) tablet by mouth two (2) times a day related to Unspecified Sequelae of Cerebral Infarction. However, review of Resident #47's PPS Sixty (60)-day MDS Assessment, dated 03/15/19, Section N0410E was coded with zero (0) indicating Resident #47 had not taken anti-coagulant medication during the seven (7)-day look-back period. Interview with with MDS Coordinator on 04/05/19 at 8:52 AM, revealed Resident #47 was taking the anti-coagulant, Apixaban, during the seven (7)-day look-back period for the PPS Sixty (60)-day MDS Assessment and the medication should have been coded on the MDS. She stated the medication was overlooked when completing the MDS Assessment. 2. Record review revealed the facility admitted Resident #51 on 12/10/18 with diagnoses which included Unspecified Atrial Fibrillation (A-fib). Review of Resident #51's April 2019 Physician's Order Sheet revealed an order initiated on 12/10/18 for Apixaban (Eliquis, an anti-coagulant) tablet 2.5 milligrams (mg), give one (1) tablet by mouth two (2) times a day for A-fib. However, review of Resident #51's PPS Quarterly MDS Assessment, dated 03/19/19, Section N0410E was coded with zero (0) indicating Resident #47 had not taken anti-coagulant medication during the seven (7)-day look-back period. Interview with the MDS Coordinator on 04/04/19 at 10:44 AM revealed Resident #51 was taking the anti-coagulant, Apixaban, during the seven (7)-day look-back period for the Quarterly MDS assessment and the medication should have been coded on the MDS. She stated the medication was an oversight/coding error when completing the MDS Assessment. Interview with the Director of Nursing (DON) on 04/04/19 at 10:32 AM revealed she expected the MDS to be coded accurately and to reflect the care the residents received. 3. Review of the RAI Manual, Version 3.0 User Manual, Section J, Health Conditions, states: Code 0, no: if the resident has not had any fall since the last assessment; and Code 1, yes: if the resident has fallen since the last assessment. Record review revealed the facility admitted Resident #37 on 10/17/16 with diagnoses which included Unsteadiness on Feet, History of Falling, and Dementia With Behavioral Disturbance. Review of an Event Summary Report revealed Resident #37 fell on [DATE]; however, review of the Quarterly MDS assessment, Section J-Health Conditions, dated 03/25/19, revealed the resident had not fallen since prior assessment. Interview with MDS Coordinator on 04/04/19 at 4:17 PM, revealed she reviewed nurses notes to see if the resident has had any falls. She stated she coded the assessment in error. The MDS Coordinator stated she was expected to ensure the accuracy of the MDS assessments that she codes. Interview with the Director of Nursing (DON) on 04/05/19 at 10:22 AM, revealed she expected the MDS assessments to be coded correctly to reflect the resident's status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, it was determined the facility failed to develop a comprehensive person-centered care plan for four (4) of seventeen (17) sampled residents (Residents #42, #47, #51 and #157). Residents #42, #47, and #157 were assessed to be incontinent of bowel and bladder and Resident #51 was assessed to be incontinent of bladder; however, the facility failed to develop a Comprehensive Care Plan to address the residents' incontinent status. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed a comprehensive, individualized care plan will be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. 1. Record review revealed the facility readmitted Resident #42 on 03/05/19 with diagnoses which included Vascular Dementia with Behavioral Disturbance and Unspecified Psychosis not due to Substance. Review of the 14-Day Minimum Data Set (MDS) Assessment, dated 03/22/19, revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was frequently incontinent of bladder and bowel and was not on a toileting program. Review of the admission Nursing Assessment, dated 03/05/19, revealed Resident #42 had bowel and bladder incontinence. However, review of the Comprehensive Care Plan revealed Resident #42 required assistance/was dependent for Activities of Daily Living (ADL) care in toileting, dated 08/28/18., with no interventions to address toileting assistance of incontinent status. Additionally, there was no documented evidence that the resident's bladder and bowel continence status or the necessary care was addressed in a care plan. 2. Record review revealed the facility admitted Resident #157 on 03/29/19 with diagnoses which included Unspecified Dementia without Behavioral Disturbance and Chronic Kidney Disease, unspecified. Review of the admission MDS Assessment, dated 04/05/19, revealed the facility assessed Resident #157's cognition as severely impaired with a BIMS score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and bowel. Review of the admission Nursing assessment dated [DATE], revealed Resident #157 had bladder and bowel incontinence. However, review of the Comprehensive Care Plan for Resident #157 revealed the resident required assistance/was dependent for ADL care in . toileting, dated 03/29/19. with no documented interventions to meet the resident's toileting needs nor was there documented evidence that the resident's bladder and bowel continence status or the necessary care was addressed in a care plan. 3. Record review revealed the facility admitted Resident #47 on 01/14/19 with diagnoses which included Chronic Kidney Disease, Stage 3, Unspecified Dementia without Behavioral Disturbance, and Unspecified Sequelae of Cerebral Infarction. Review of the Perspective Pay System (PPS) 60-day MDS Assessment, dated 03/15/19, revealed the facility assessed Resident #47's cognition as severely impaired with a BIMS score of five (5), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was always incontinent of bladder and bowel. Review of the admission Nursing assessment dated [DATE], revealed Resident #47 had bladder and bowel incontinence. However, review of the Comprehensive Care Plan for Resident #47 revealed the resident required assistance/was dependent for ADL care in toileting, dated 01/14/19. with no documented interventions to meet the resident's toileting needs nor was there documented evidence that the Resident's bladder and bowel continence status or the necessary care was addressed in a care plan. 4. Record review revealed the facility admitted Resident #51 on 12/20/18 with diagnoses which included Unspecified Dementia without Behavioral Disturbance. Review of the Quarterly MDS Assessment, dated 03/19/19, revealed the facility assessed Resident #51's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and always continent of bowel. Review of the admission Nursing assessment dated [DATE], revealed Resident #51 had bladder incontinence. However, review of the Comprehensive Care Plan for Resident #51 revealed the resident required assistance/was dependent for ADL care in . toileting, dated 12/10/18. with no documented interventions to meet the resident's toileting needs nor was there documented evidence that the resident's bladder and bowel continence status or the necessary care was addressed in a care plan. Interview with the MDS Coordinator on 04/04/19 at 10:47 AM revealed she was responsible for initiating the comprehensive and quarterly care plans and the residents' continence status should have been added to the comprehensive care plans on admission. She stated it was probably an oversight because normally incontinence was addressed with the ADL's. Interview with the Director of Nursing (DON) on 04/05/19 at 10:31 AM revealed she expected a care plan to be developed to address residents who are incontinent.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of seventeen (17) sampled residents (Resident #47). Resident #47 was care planned to float heels while in bed; however, observations on 04/02/19 and 04/03/19 revealed his/he heels were not floated while in bed. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed a comprehensive, individualized care plan will be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Record review revealed the facility admitted Resident #47 on 01/14/19 with diagnoses which included Chronic Kidney Disease, Stage 3, Unspecified Dementia without Behavioral Disturbance, and Unspecified Sequelae of Cerebral Infarction. Review of the Perspective Pay System (PPS) 60-day Minimum Data Set (MDS) Assessment, dated 03/15/19, revealed the facility assessed Resident #47's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5), which indicated the resident was not interviewable. Review of the Comprehensive Care Plans for Resident #47, last revised 03/20/19. revealed the resident had actual skin breakdown on admission and a healed unstageable to left heel,with an intervention to float heels while in bed. However, observation on 04/02/19 at 2:24 PM revealed Resident #47 was in bed, sleeping on his/her back, and his/her feet/heels were not elevated. A sign was noted over the resident's bed stating heels up while resting in bed. Further observation on 04/03/19 at 10:12 AM revealed the resident's heels were not elevated, but flat on the mattress. Interview with Certified Nurse Assistant (CNA) #1 on 04/03/19 at 10:25 AM revealed Resident #47's feet should be elevated when in bed, as the sign over the resident's bed states. Interview with Registered Nurse #2 on 04/03/19 at 10:12 AM revealed Resident #47's feet should be elevated when he/she is in bed, and acknowledged they were not at that time. Interview with the Director of Nursing (DON) on 04/05/19 at 10:31 AM revealed she expected for the resident's heels to be elevated per the care plan, and she expected staff to follow the care plan as it was written.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure residents who display or are diagnosed with dementia, receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (1) of seventeen (17) sampled residents (Resident #43). Record review revealed no documented evidence the facility developed and implemented a person-centered care plan that included and supported the dementia care needs of Resident #43 which included communication and mood concerns. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed the center must develop and implement a baseline person-centered care plan for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Person-centered care means to focus on the resident as the lotus of control and support the resident in making his/her own choices and having control over his/her daily life. A comprehensive, individualized care plan will be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Record review revealed the facility admitted Resident #43 on 12/06/18 with diagnoses which included Unspecified Dementia with Behavioral Disturbance. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/12/19, revealed the facility assessed Resident #43's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan dated 12/14/18, revealed the resident has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Dementia (other than Alzheimer's disease) with a goal that the resident will be able to make simple decisions by responding yes or no on most days throughout the next review period. Further review revealed interventions to use short phrases that request yes or no answers; allow extra time after speaking for resident to process thoughts and respond; and provide opportunities to the resident to reminisce, i.e. using photos of family/friends/pet. However, the care plan did not guide staff on how to address the noted mood issues this resident exhibited as part of the Dementia diagnosis. Interview with the Dementia Program Director (DPD) on 04/05/19 at 9:20 AM revealed she believed that the dementia care plan was person-centered. However, on first review, on 04/04/19 the cognition care plan were not individualized or person-centered. When reviewing the care plan again on 04/05/19 revealed the dementia care plan had been revised on 04/04/19. The care plan was revised to reflect the following interventions: use short phrases with resident that require yes or no answers or that resident can answer by non-verbal communication such as nodding her head or shaking her head as indicated for yes or no; give the resident two options such as picking out clothing, or asking the resident if she wants to participate in her favorite activities, and when doing so allow extra time for the resident to respond; and provide opportunity to the resident/patient to reminisce about photos by asking if she can recall family and loved one's names or is she can point to family or loved one's face in picture. Additionally, a new care plan was initiated that identified the resident exhibits or is at risk for signs and symptoms of depression related to diagnosis of Major Depressive Disorder. Interview with the Director of Nursing (DON) on 04/05/19 at 10:23 AM revealed care planning was new to the DPD and she was learning. She stated it was the responsibility of the MDS Coordinator and the DON to oversee the care plan process until the DPD was proficient at care planning. The DON stated the dementia care plan, prior to the 04/04/19 update, was not person-centered or individualized for Resident #43. The DON stated she expected going forward, the care plans to be more person-centered and individualized for the specific resident and for us (DON and the MDS Coordinator) to oversee the process more closely.

Based on interview, record review, and review of the Nursing Drug Handbook by Lipponcott, it was determined the facility failed to ensure one (1) of seventeen (17) sampled residents was administered a psychotropic medication without an appropriate diagnosis (Resident #43). Record review revealed Resident #43 was administered Risperidone (Risperdal-an antipsychotic) with a diagnosis of Dementia with Behavioral Disturbance which was not an appropriate diagnosis for the use of Risperidone. The findings include: Interview with the Director of Nursing (DON) on 04/05/19 at 10:23 AM revealed the facility was unable to provide a policy for psychotropic medication use. Review of a Nursing Drug Handbook by Lipponcott, dated 2014, revealed Risperidone was used for the following: Schizophrenia, Aggression, Irritability, Temper Tantrums, and Self-Injury associated with Autism, and Tourette's Syndrome. Review of the Black Box Warning revealed fatal Cardiovascular or Infectious adverse events may occur in elderly patients with dementia and is not safe or effective in these patients. Record review revealed the facility admitted Resident #43 on 12/06/18 with diagnoses which included Unspecified Dementia with Behavioral Disturbance. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/12/19, revealed the facility assessed Resident #43's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the MDS revealed the resident did not have hallucinations, delusions, rejection of care, wandering, no other behaviors were exhibited, and there were no mood indicators coded on the MDS. Additionally, review of Section N0450B, Antipsychotic Medication Review, revealed the physician documented gradual dose reduction as clinically contraindicated. Review of Resident #43's Physician's Order Summary for April 2019 revealed an order initiated 12/05/18 for Risperidone tablet 0.5 milligram (mg), give one (1) tablet by mouth two (2) times a day for dementia with behavioral disturbance. Review of Behavior Monitoring and Intervention Sheets for Resident #43 for December, 2018; January, 2019; February, 2019, and March, 2019, revealed the resident had zero (0) behaviors since admission. Review of the Comprehensive Care Plans for Resident #43 revealed the resident is at risk for complications related to the use of psychotropic drugs Medication: Risperdal, dated 12/20/18. Listed interventions included complete behavior monitoring flow sheet; and monitor for continued need of medication as related to behavior and mood. Review of the Pharmacy review sheet revealed Resident #43's medications were reviewed on 1/29/19, 02/16/19, and 03/26/19 with no irregularities noted. Interview with the Director of Nursing (DON) on 04/05/19 at 10:23 AM revealed Resident #43 was prescribed Risperidone on admission and had only been in the facility three (3) months. She stated the physician will not order a gradual dose reduction or discontinue a psychotropic medication without first monitoring the resident's behavior. The DON further stated she was not aware of the reason Risperidone was ordered to begin with. Additionally, the DON stated she was aware that Dementia with Behavioral Disturbance was not an appropriate diagnosis for an antipsychotic, but had not made the physician aware of this. Interview with Resident #43's attending Physician/ Medical Director on 04/05/19 at 10:48 AM revealed the resident was admitted with Risperidal ordered and with the diagnosis of Dementia with Behaviors. He stated the resident had only been in the facility for approximately three (3) months and protocol was to monitor the resident for a period of time then begin to gradually reduce the medication. He revealed Risperdal was typically prescribed for Schizophrenia and Bi-polar Disorder. He further stated he understood that Dementia with Behavior Disturbance was not an appropriate diagnosis for prescribing this medication, however, he stated he would not change the medication or the diagnosis without first monitoring the resident for a period of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure that a resident who is incontinent of bladder and/or bowel receives appropriate treatment and services to prevent urinary tract infection and to restore as much continence as possible for six (6) of seventeen (17) sampled residents (Residents #16, #26, #42, #47, #51, and #157). Record review revealed the facility failed to complete a three-day continence management diary on admission and/or when a decline in bladder and bowel continence occurred for Residents #42, #47, and #51. Additionally, a bladder and bowel program was not implemented to restore as much bladder and bowel function as possible for Residents #42, #47, and #51 per facility policy. The findings include: Review of the facility policy titled, Continence Management, last revised [DATE], revealed a urinary incontinence assessment and/or bowel incontinence assessment and the Three-Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. Purpose: to provide appropriate treatment and services for patients with urinary incontinence to minimize urinary tract infections and restore as much normal elimination function as possible; and to provide appropriate treatment and services for patients incontinent of bowel to restore as much bowel function as possible. 1. Record review revealed the facility readmitted Resident #42 on [DATE] with diagnoses which included Vascular Dementia with Behavioral Disturbance and Unspecified Psychosis not due to Substance. Review of a Three-Day Continence Management Diary dated [DATE] revealed the diary section of the evaluation was completed and revealed the resident was incontinent only one (1) time over a three (3)-day period. All other hourly checks were coded CD, indicating the resident was clean and dry. Further review of the diary revealed the sections of the form indicating the type of incontinence, type of program, licensed staff signature, or date of the assessment was not filled in or completed per facility policy. Review of the admission Nursing Assessment, dated [DATE], revealed Resident #42 had bowel and bladder incontinence with no toileting program. Review of the 14-Day Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was frequently incontinent of bladder and bowel and was not on a toileting program. Review of the Comprehensive Care Plan revealed Resident #42 required assistance/was dependent for Activities of Daily Living (ADL) care in . toileting, dated [DATE]. Further review of the care plan revealed there were only two (2) interventions to meet the resident's care needs: provide resident/patient with extensive assist of two for bed mobility, and provide resident/patient with extensive assist of two (2) for transfers using pivot transfers. There was no documented intervention for toileting assistance or to address incontinent status. 2. Record review revealed the facility admitted Resident #47 on [DATE] with diagnoses which included Chronic Kidney Disease, Stage 3, Unspecified Dementia without Behavioral Disturbance, and Unspecified Sequelae of Cerebral Infarction. Review of the admission Nursing assessment dated [DATE], revealed Resident #47 had bladder and bowel incontinence with no toileting program. Review of a Three-Day Continence Management Diary revealed it had the three (3)-day assessment dates filled in ([DATE], [DATE], and [DATE]), however, the hourly diary was not completed as on admission per facility policy, as the form was blank. Review of the admission MDS assessment, dated [DATE], revealed the resident was frequently incontinent of bladder and bowel. Review of the Perspective Pay System (PPS) 60-day MDS Assessment, dated [DATE], revealed the facility assessed Resident #47's cognition as severely impaired with a BIMS score of five (5), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was always incontinent of bladder and bowel and was not on a toileting program, which was a decline in continence status from the previous MDS assessment. However, further review of Resident #47's medical record revealed there was no documented evidence that a Three-Day Continence Management Diary was completed for the 60-day assessment when a decline in continence status was evident, per facility policy. Review of the Quarterly Nursing Assessment, dated [DATE], revealed Resident #47 is always incontinent of bladder and bowel with no toileting program. Review of the Comprehensive Care Plan for Resident #47 revealed the resident required assistance/was dependent for ADL care in . toileting, dated [DATE]. Further review of the care plan revealed there was no documented interventions to meet the resident's toileting needs. 3. Record review revealed the facility admitted Resident #51 on [DATE] with diagnoses which included Unspecified Dementia without Behavioral Disturbance. Review of the admission Nursing assessment dated [DATE], revealed Resident #51 had bladder incontinence with no toileting program. The resident's bowel continence status was not indicated on the assessment. Review of a Three-Day Continence Management Diary revealed the three (3)-day assessment dates were filled in ([DATE], [DATE], and [DATE]), however, the hourly diary was not completed on admission per facility policy, as the form was blank. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #51's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and always continent of bowel, and there was not a toileting program initiated. Review of the Comprehensive Care Plan for Resident #51 revealed the resident required assistance/was dependent for ADL care in . toileting, dated [DATE]. Further review of the care plan revealed there was no documented interventions to meet the resident's toileting needs. 4. Record review revealed the facility admitted Resident #157 on [DATE] with diagnoses which included Unspecified Dementia without Behavioral Disturbance and Chronic Kidney Disease, unspecified. Review of the admission Nursing assessment dated [DATE], revealed Resident #157 had bladder and bowel incontinence with no toileting program. Review of the admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #157's cognition as severely impaired with a BIMS score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was occasionally incontinent of bladder and bowel and was not on a toileting program. Review of a Three-Day Continence Management Diary revealed the three (3)-day assessment dates were ([DATE], [DATE], and [DATE]). However, on [DATE], Resident #157's continence status was assessed hourly from 1:00 PM to 6:00 AM and indicated the resident was incontinent only one (1) time during that time frame, and was coded as C/D (Clean and Dry) the remainder of the times. Additionally, the hourly checks from 7:00 AM to 12:00 AM on [DATE] were not completed. Further review revealed the resident was assessed to be clean and dry only three (3) times on [DATE], at 7:00 AM, 8:00 AM, and 9:00 AM. Assessment was not completed for [DATE] and the other sections of the evaluation was not completed. Review of the Comprehensive Care Plan for Resident #157 revealed the resident required assistance/was dependent for ADL care in . toileting, dated [DATE]. Further review of the care plan revealed there was only two (2) interventions listed on the care plan: provide resident with limited assist of one (1) for bed mobility, and provide resident with limited assist of one (1) for transfers using a roll walker. There was no documented interventions to meet the resident's toileting needs. 5. Record review revealed the facility admitted Resident #16 on [DATE], with diagnoses which included, Major Depressive Disorder, Unspecified Urinary Incontinence, and Alzheimer's Disease. Review of the admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #16's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was always incontinent of bladder and bowel and was not on a toileting program. Review of the Initial (Admission) Nursing assessment dated [DATE], revealed Resident #16 had bladder and bowel incontinence with no toileting program. Review of Resident #16's Bowel and Bladder Continence Evaluation revealed it had the three (3)-day assessment dates filled in ([DATE], [DATE], and [DATE]) for 11-7 shift, however, the hourly diary for 7-3 PM and 3-11 PM shifts were blank on all three days. Review of Resident #16's Bowel Retraining Evaluation, dated [DATE], revealed the reason for the incontinence was due to disease process. Review of the Comprehensive Care Plan for Resident #16 revealed the resident required assistance/was dependent for ADL care for toileting, dated [DATE]. Further review of the care plan revealed staff to provide incontinent care. 6. Record review revealed the facility admitted Resident #26 on [DATE], with diagnoses which included, Major Depressive Disorder, Unspecified Urinary Incontinence, and Unspecified Dementia with Behavioral Disturbance. Review of the Initial (Admission) Nursing assessment dated [DATE], revealed Resident #26 had bladder and bowel incontinence with no toileting program. Review of the admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #26's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident was frequently incontinent of bladder and occasionally of bowel and was not on a toileting program. Review of Resident #26's record revealed there was no documented evidence a Bowel and Bladder Continence Evaluation had been initiated on admission per facility policy. Review of the Comprehensive Care Plan for Resident #26 revealed the resident required staff assistance/was dependent for ADL care in for toileting, dated [DATE]. Further review of the care plan revealed staff assistance of one (1) with toileting and provide incontinent care. Interview with Certified Nurse Aide (CNA) #3 on [DATE] at 11:08 AM, revealed when residents are admitted there will be a bowel/bladder form in the ADL book for the aides to complete for three days on whether the resident is incontinent. She stated when the form is complete she usually leaves it in the book because the Assistant Director of Nursing (ADON) will take it out when done. Interview with CNA #4 on [DATE] at 5:07 PM, revealed the bowel and bladder forms are kept in the CNA's ADL book when new admits come in and are documented on every hour for the resident as to whether they are wet or staff toileted them. CNA #4 stated once the form is completed it's given to the nurse working or the ADON. She further revealed if she noticed that a new admit did not have a form in the ADL book she would let the nurse know so one could be completed. Interview with Registered Nurse (RN) #2 on [DATE] at 8:06 AM revealed she worked sporadically and on whatever shift she was needed, but on occasion she admitted a new resident. RN #2 stated she initiated the 3-day bladder evaluation sheet and placed it in the ADL books then reminded the Certified Nurse Assistants (CNA's) that the evaluations needed to be completed for the resident. RN #2 revealed when she was working when the three (3) days have expired, the sheets were pulled from the ADL books and either placed in the to-be-filed basket or she gave them to the ADON or the Director of Nursing (DON). RN #2 stated she has never seen one that has not been filled out completely, but if she did, she would ask the ADON if the thee (3) days should be started over because there would not be enough data to make a decision on the continent status of the resident. RN #2 further stated, in her professional opinion, she would expect the CNA's to complete the Three-Day Continence Management Evaluations per policy. Interview with RN #1 on [DATE] at 9:29 AM revealed the three-day bowel and bladder sheets are placed in the ADL book on admission for the CNA's to complete after the name and date is written in. RN #1 stated she does tell the CNA's, but assumes the CNA's know the sheet is in the ADL book. RN #1 stated she periodically checks the CNA book but has not found a sheet that was not completed and needed to be pulled. Interviews with the ADON on [DATE] at 9:33 AM and at 4:23 PM revealed she and the DON are responsible for assuring the Three-Day Continence Management Evaluations are completed and the MDS Coordinator is responsible for assuring the bowel and bladder care plans are initiated. The ADON stated the Evaluations should have been initiated on the date of admission based on the Nursing Assessment indicating incontinence. She stated the interdisciplinary team audits the ADL books after admission to assure all areas are covered, but obviously these were missed. She stated the evaluation sheets are placed in the ADL books for the CNA's to complete daily, and she does not have any idea why the CNA's are not completing the evaluations. Interview with the DON on [DATE] at 9:57 AM revealed the ADON was responsible for over seeing the bowel and bladder program. She stated residents who are admitted or readmitted with incontinence will have a three day continence diary completed. She stated it helps identify patterns of incontinence and will be addressed on the resident's care plan. The DON stated the evaluation form is placed in the CNA's ADL book by the admitting nurse and the CNA's complete the form and it is given to the ADON or herself.