Based on interview, personnel record review, and facility policy review, it was determined the facility failed to ensure contracted employees had a Kentucky Adult Caregiver Misconduct Registry check prior to employment as required by KRS 209.032 for 5 of 7 contracted employee files sampled. The facility provided an acceptable plan for the removal of this deficiency on 11/01/2024. This plan alleged the deficiency was corrected on 10/28/2024, prior to the initiation of the survey. The plan provided by the facility alleged the following: 1. On 10/28/2024 the Administrator audited all dietary and housekeeping contracted employees. Each employee had a Kentucky Adult Caregiver Misconduct Registry (KACMR) check completed. 2. On 10/28/2024 the Housekeeping Supervisor and Dietary Manager were educated by the Administrator on the requirement for all new employees to have a completed KACMR check prior to beginning employment. Results must be sent to the contracted company's payroll department. The new employee will not be eligible for hire until all parameters of their background check were completed, including the KACMR check. 3. Beginning 10/29/2024 the Administrator, Director of Nursing (DON), or Business Office Manager will complete audits of new houskeeping and dietary employees to ensure the KACMR checks were completed before hire, 5 times a week for 2 weeks, 3 times a week for 2 weeks, weekly for 4 weeks, then monthly. Audits were completed on 10/29/2024, 10/30/2024, 10/31/2024 by the Administrator with no new contracted employees hired. 4. A Quality Assurance (QA) meeting held on 10/28/2024 formulated and implemented the plan. Audits will be reviewed in the monthly QAPI meeting until 100% compliance is achieved. Through record review and interview the State Survey Agency validated the facility implemented the plan of correction as alleged. The findings include: Review of the facility policy Abuse, Neglect and Misappropriation of Property, reviewed 09/13/2024, revealed the facility included screening to provide protection for the health, welfare, and rights of each resident residing in the facility. Continued review revealed the screening included conducting criminal background checks and a search of the State Aide Registry. Review further revealed however, the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks were not included as part of the screening. Review of the Kentucky Revised Statutes (KRS) 209.032 revealed a vulnerable adult services provider, such as a long term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation -- Administrative regulations -- Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. 1. Review of the personnel file for Housekeeper 1 revealed the facility employed her through a contracted company on 08/02/2024. Further review revealed the facility conducted the check of the Kentucky Adult Caregiver Misconduct Registry (KACMR) on 08/26/2024. 2. Review of the personnel file for Housekeeper 2 revealed the facility employed her through a contracted company on 08/21/2024. Further review revealed the facility conducted the check of the KACMR on 08/26/2024. 3. Review of Dietary Aide (DA) 3's personnel file revealed she was employed by the facility on 08/01/2024 through a contracted company. Further review revealed the facility conducted the check of the KACMR on 08/27/2024. 4. Review of the personnel file for DA 4 revealed he was employed by the facility through a contracted company on 07/23/2024. Further review revealed the facility conducted the check of the KACMR on 08/26/2024. 5. Review of the personnel file for DA 5 revealed she was employed by the facility on 09/03/2024 through a contracted company. Further review revealed the facility conducted the check of the KACMR on 09/09/2024. In interview on 11/01/2024 at 10:05 AM, the Director of Nursing (DON) stated she could not speak to the KACMR checks as she had only been with the facility a couple of weeks. She stated her expectation was for all staff checks be completed before staff entered the building. The DON stated the purpose of the checks was for the safety of the residents. She further stated if the checks were not completed timely there was a potential issue with safety of residents. In interview with the Signature Care Consultant (SCC) on 11/01/2024 at 10:33 AM, she stated the facility did not have a permanent DON for about 1 month and the current DON was there about 3 to 4 weeks. She stated the facility expected contracted staff have checks completed prior to working. The SCC further stated the purpose of the checks was to ensure the employee was not listed on the abuse registry. She also stated if the checks were not completed it was possible the facility could hire someone who could be listed on the abuse registry, and was against the regulation. The SCC stated on 10/28/2024, the facility identified the KACMR checks were not completed for contracted staff. She further stated on 10/28/2024, the facility held a QAPI meeting and conducted an audit of contracted staff who did not have the KACMR checks completed at the time they were hired. She also stated the Housekeeping and Dietary Managers were educated on completing the checks. In interview on 11/01/2024 at 10:57 AM the Housekeeping Manager stated the facility identified an issue with the completion of the KAGMR checks and had a QAPI meeting on 10/28/2024. She stated an audit of the (contracted) staff was completed on 10/28/2024. She also stated she was unaware of the requirement to complete the KAGMR checks and was informed by the Administrator. She stated the Administrator asked about new employees in housekeeping and dietary departments, with no new staff hired. In interview on 11/01/2024 at 11:05 AM the Dietary Manager stated she was made aware of the KACMR checks and a QAPI plan was immediately put in place by the facility on 10/28/2024. She stated all current employee files were audited and a plan put in place that no one would be on the payroll until the KACMR check was completed. She stated the audits were reviewed with the QAPI committee. She also stated her department did not have any new employees. In interview on 11/01/2024 at 10:47 AM, the Administrator stated the contracted company was required to complete the KACMR checks, per their contract, before the employee started working. He stated the purpose of the checks was to identify anyone that had issues in the past and to ensure the safety of residents. He further stated a Signature Healthcare employee would not be able to work without the check completed. The Administrator stated the facility self-identified and put a plan in place to ensure contracted staff had the KACMR checks completed. He further stated he completed an audit of contracted staff and educated the housekeeping and dietary managers. He also stated the two departments have not hired any new employees this week.

483.60 Based on observation, interview and record review, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of two nourishment refrigerators. Observation revealed the nourishment refrigerator on the Dogwood unit had two bowls of applesauce unlabeled or undated. The findings include: Review of the facility's policy, Food: Preparation, revised 2/2023, revealed all refrigerated, ready to eat foods held for more than twenty four (24) hours at a temperature of forty one (41) degrees Fahrenheit (F) or less, would be labelled and dated with a prepare date (day one) and a use by date (day seven). Review of the facility's policy, Food: Safe Handling for Foods from Visitors, dated 9/2017, revealed when food items were intended for later consumption, the responsible facility staff member labeled the food with the resident's name and the current date. Further review of the policy revealed there was daily monitoring of refrigerator storage duration and any food items stored more than seven days would be discarded. Observation of the nourishment refrigerator on the Dogwood unit, on 10/30/2024 at 8:33 AM, revealed two bowls of applesauce not labeled with a resident's name and not dated. During interview with the Dietary Manager and [NAME] 1 on 10/30/2024 at 9:46 AM, both stated all food from the kitchen except food placed on resident dining trays would be labeled with a name and date, including snacks. The only exception was the applesauce given to the nursing staff for medication administration. This applesauce would only have the date prepared and date to be discarded. During an interview with the Registered Dietician (RD) on 10/31/2024 at 8:44 AM she stated she expected food to be dated and labelled with a resident's name. During an interview with License Practical Nurse (LPN) 1 on 10/31/2024 at 12:11 PM LPN1 stated when residents had left over food from their meal tray and wanted it stored in the nourishment refrigerator, whomever placed it in the refrigerator was responsible for placing the resident's name and the preparation and use by date upon the food. This also included any foods brought by a resident's family. During an interview with the Director of Nursing (DON) on 11/01/2024 at 9:51 AM she stated her expectation was all food should be labeled with the date family brought it in, if it was brought from the outside along with the resident's name. Nursing staff should place this information on the food prior to placing it in the nourishment refrigerator. During an interview with the Administrator on 11/01/2024 at 9:57 AM he stated he expected the nursing staff would label and date the food prior to placing it in the refrigerator. He stated he was unsure if left over food from residents' trays were placed in the nourishment refrigerator. He stated that if left over food from a resident's tray was placed in the refrigerator that it was his expectation that it would be labeled with the resident's name and the date placed in the refrigerator.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify a resident's physician regarding the significant weight loss for one (1) of twenty-two (22) sampled residents, Resident #77. Review of the medical record revealed no documentation regarding notification to the physician of Resident #77's weight loss of more than five (5) percent (%) in a one (1) month period. The findings include: Review of the facility policy, Change of Condition, revised 07/10/18, revealed the facility evaluated and documented a resident's health and mental or psychosocial status efficiently and effectively, to relay the evaluation information to a physician. Additionally, the facility documented actions including a significant change in resident's physical, mental or psychosocial status. Further review revealed the facility documented notifications in the resident's medical record. Review of the medical record revealed the facility admitted Resident #77 on 12/01/15 with diagnoses including Other Alzheimer's Disease (Primary), Unspecified Dementia with Behavioral Disturbance, Dysphagia Oropharyngeal Phase, Morbid Obesity, and Anemia Unspecified. Review of the comprehensive care plan for Resident #77, revealed the Problem, dated 04/15/19, the resident was a nutrition risk due to diagnoses including Alzheimer Dementia, Dysphagia, Anemia, and Morbid Obesity, and resident has therapeutic/mechanically altered diet. The interventions for this problem included monitoring meal intake, weights per order, diet as ordered, and the dietician to review quarterly and as needed. Review of the Vitals Report revealed the facility recorded the resident's weight on 06/05/19 at one hundred, forty-eight point two (148.2) pounds and on 07/15/19 at one hundred thirty-nine point six (139.6) pounds. A weight loss of eight point six (8.6) pounds, or five point eight (5.8) percent. Review of the resident progress notes for Resident #77, dated 07/17/19, revealed documentation recorded by the Assistant Director of Nursing (ADON), elder has had six point three percent (6.3%) weight loss in one month. Stable at this time at one hundred, thirty-nine point six (139.6). Elder receives pureed diet and SNP all meals. Will follow. Continued review of the medical record revealed no documentation of physician notification of the weight loss. Interview with the Dietician, on 08/01/19 at 11:36 AM, revealed she had no record of notification from the facility regarding Resident #77's weight loss. The Dietician stated the facility staff notified her of resident significant weight changes, admissions, or pressure ulcers. She stated staff notification to her of a resident's weight loss caused her to perform a nutritional assessment of a resident. The Dietician stated a resident could experience skin break down, continued weight loss, a decrease in activities of daily living, potential hospitalization, or dehydration if not assessed for nutrition concerns. Interview with Registered Nurse (RN) #1, on 08/02/19 at 10:20 AM, revealed the Dietary Manager (DM) monitored for resident weight loss, in conjunction with the ADON. RN #1 stated either the DM or the ADON contacted the resident's physician for notification and for orders. Additionally, RN #1 stated it was a nursing responsibility to ensure the facility notified providers of resident weight loss. She stated no notifications of a resident's weight loss could lead to additional weight loss, or skin breakdown. Interview with the Physician (MD), on 08/02/19 at 10:57 AM, revealed he could not verify if facility staff notified him Resident #77's weight loss. The MD stated if notified he could then follow the dietician recommendations for a resident with weight loss, in addition to weight monitoring and evaluation of a resident's needs. The MD stated a resident with weight loss and nutrition concerns could experience skin breakdown, wound healing, and generalized weakness. Interview with the DM, on 8/02/19 at 11:22 AM, revealed the ADON made the weight loss notifications to the physicians and stated she did not follow up with the ADON to insure she made the notification. The DM stated the facility was responsible to notify physicians of a resident's weight loss and their failure to do so could lead to additional weight loss. Interview with the Unit Manager (UM), on 08/02/19 at 12:13 PM, revealed she was aware of Resident #77's weight loss but did not notify the physician. The UM stated failing to make the notifications could potentially lead to additional weight loss, making the resident very ill. The UM stated the nurse who assessed a resident with significant weight loss was responsible to insure physician notification occurred. Interview with the ADON, on 08/02/19 at 12:47 PM, revealed nursing was responsible to notify a physician when staff assessed a resident with significant weight loss. The ADON stated failure to notify a physician of a resident's weight loss could lead to missed laboratory testing or potential medication changes. Interview with the Director of Nursing, on 08/02/19 at 1:09 PM, revealed either the UM or her designee called the physician with notification of a resident's significant weight loss. The DON stated a resident with long-term weight loss could develop skin problems.

Based on interview, record review, and facility policy review it was determined the facility failed to develop a comprehensive care plan for one (1) of twenty-two (22) sampled residents, Resident #77. The facility identified Resident #77 sustained significant weight loss (five (5) percent or more), however, the facility did not address the Problem in the resident's person-centered comprehensive care plan. The findings include: Review of facility policy Comprehensive Care Plans, dated 07/19/18, revealed the facility developed person-centered comprehensive care plans, which included measurable objectives and timetables that met residents' medical, nursing, mental and psychosocial needs. The facility's Comprehensive Care Plans policy was also designed to identify residents' problem areas, risk factors associated with identified problems, and assist with preventing and/or reducing declines in residents' functional capabilities. Continued review of the policy revealed when a resident's condition significantly changed the nurse/Interdisciplinary Team (IDT) would develop, reviewed, and/or revise their Comprehensive Care Plan. Review of Resident #77's medical record revealed the facility admitted the resident on 12/01/15, with diagnoses of Other Alzheimer's Disease (Primary), Unspecified Dementia with Behavioral Disturbance, Dysphagia Oropharyngeal Phase, Morbid Obesity, and Anemia Unspecified. Review of Resident #77's Vitals Report revealed the facility recorded the resident's weight at one hundred forty-eight point two (148.2) pounds on 06/05/19 and at one hundred thirty-nine point six (139.6) pounds on 07/15/19. The recorded weight calculation for Resident #77 revealed a significant weight loss of eight point six (8.6) pounds or five point eight percent (5.8%). Review of Resident #77's Progress Notes recorded by the Assistant Director of Nursing (ADON), dated 07/17/19, revealed she documented the resident had a six point three percent (6.3%) weight loss within one (1) month with a stable weight of one hundred thirty-nine point six pounds (139.6). The ADON also documented Resident #77 received a pureed diet and Supplemental Nutritional Program (SNP) with all meals. Continued review of Resident #77's Progress Notes revealed no documentation that staff notified the physician and/or Dietician of the resident's significant weight loss. Review of the Comprehensive Care Plan for Resident #77, dated 04/15/19, revealed the facility determined the resident was at risk for malnutrition due to diagnoses of Alzheimer Dementia, Dysphagia, Anemia, Morbid Obesity, and was ordered to receive a therapeutic/mechanically altered diet. The Comprehensive Care Plan's Interventions for Resident #77's risk of malnutrition included monitoring meal intake, monitoring weight, receiving meals according to ordered diet, and quarterly or as needed Dietician reviews. Continued review of Resident #77's Comprehensive Care Plan revealed no documentation addressing the resident's significant weight loss (of more than five (5) per cent within one (1) month). Interview with the Minimum Data Set (MDS) Coordinator, on 08/02/19 at 9:38 AM, revealed the Dietary Manager (DM) was responsible for completion of the portion of the assessment that triggered a comprehensive care plan related to resident nutrition. The MDS Coordinator stated the assigned staff member was then responsible to develop the care plan accordingly. Additionally, the MDS Coordinator stated care plans were developed during the morning meetings with the ADON, the Director of Nursing (DON), the Unit Manager (UM), and Dietary Manager (DM). The MDS Coordinator stated a fully developed, accurate care plan directly affected the care staff provided to residents. Interview with Certified Nursing Assistant (CNA) #1, on 08/02/19 at 10:16 AM, revealed she was unsure when the facility developed new areas for comprehensive care plans but she knew upper nursing staff completed this task. CNA #1 stated a resident could continue to lose weight, if staff failed to develop a resident's weight loss care plan. Interview with Registered Nurse (RN) #1, on 08/02/19 at 10:20 AM, revealed nursing staff developed a resident's weight loss care plan after assessment revealed the resident lost a significant amount of weight. RN #1 stated it could be detrimental to a resident, if staff failed to develop the resident's care plan related to weight loss because many of the residents do not have a lot of weight to lose. Additionally, developing a resident's care plan to include additional assessments and interventions prevented continued weight loss. Interview with the DM, on 08/02/19 at 11:22 AM, revealed she developed the nutrition section of a resident's comprehensive care plan. The DM admitted she failed to develop the nutritional care plan for Resident #77, after she became aware of the weight loss of greater than five (5) percent in a one (1) month period. The DM stated an incomplete care plan prevented staff from providing appropriate care to residents and a resident could lose additional weight. Interview with the UM, on 08/02/19 at 12:13 PM, revealed she did not develop the comprehensive care plan for Resident #77 when the weight loss occurred and was unable to verbalize her reasoning for not developing the care plan. She stated staff developed care plans for unplanned weight loss when staff assessed the resident for weight loss and the assessment revealed a significant change. The UM stated a resident would continue to lose weight and potentially become ill, if staff did not develop the resident's care plan for significant weight loss. Interview with the ADON, on 08/02/19 at 12:47 PM, revealed staff were supposed to develop a resident's care plan for unplanned weight loss to address the weight loss and implement interventions to re-gain that weight. The ADON stated no particular staff member was responsible for developing care plans; however, the facility trained and directed all nursing staff to develop care plans as needed. She stated when Resident #77 experienced significant weight loss, staff should have initiated a new Problem area on the resident's care plan to specifically address his/her weight loss. According to the ADON, failure to develop a resident's care plan prevented staff from identifying causes of the resident's weight loss. Interview with the DON, on 08/02/19 at 1:09 PM, revealed staff developed care plans with a new Problem in the morning meeting in order to reflect a resident accurately. She stated an inaccurate care plan regarding a resident's weight could lead to additional weight loss and development of skin issues over time. Interview with the Administrator, on 08/02/19 at 4:04 PM, revealed the facility had not identified concerns regarding staff not developing comprehensive care plans upon recognition of a resident's significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** one of eight medication carts one of two nursing units Magnolia Unit and the Dogwood Unit The facility failed to follow the pharmacy process for narcotic reconciliation for one of two units. The narcotic card count was not accurate and staff failed to visualize/witness the empty narcotic card before signing off a correct count. (Magnolia unit) medication cart no citation for unlocked med cart due to orientation was ongoing with the cart and the cart was still in view of nurses FACILITY Medication Storage and Labeling [DATE] 11:01 AM [NAME] LPN- 400 cart-Nitro -09--0920, hemaocult-04-22 7 05-22, Narcan -02-20, eye gtt 2-21, miralax 01-22, lactulose-01-21 k exylate-02-21, megace 03-22, albuterol 02-21, narc- Fentanyl patches- 4 count, ambien 10 count- no problems with expiration. Disscrepancy in narc count, 22 narc sheets correct 0, narc-4- Lea [NAME] LPN- - 300 hall cart nitro-11-20, eye gtts 2-20 tussin-4-212, megace-6-2 Nursing stationMagnoal [NAME] Cerry- LPNx 21/2 years. Medication cart unlocked- resident could get medication out adverse effect on resident =med error [NAME] LPN in training-she had eyes on medication cart at all times. insulin-4-21, Vit B 1-21, inhaler 6-20 Cart 500-700 nitro-1-21eye gtts- 9-20, waste with 2 staff , put on sharps container and document on back of narc sheet Magnolia hall med room for all extra narcs- temp- 45 degrees TB serum -9-20, refib- 3-20, insulin-10-21, yello top tube 4-20, ER chart in stock room nothing expired, NS 2-23 Procedure to fdisposing narcs- 2 nurses take to DON takes 2 people to open narc box then disolve narcs , log of wasted narcs, and narcotic sheet; both sign sheet. Narcotic pkg cards count count cards when narc add to sheet then when go out take it off the sheet. No body signs off that they reordered it, put a sheet in Chart that , 2 nurses sign off and nurses should witnessed it . Is it procedure tto sign off without seeing it. No, it is ridelous to sign off something that you did not see it. They show cards to other nurse and sign off. and it should have been deducted from card sheet. Should hhave been looked at and signed off. syrgines 4-20, stock room ensure- 7-20, nephro-10-20, glucerna-9-20, 2 calHN-5-20, sterile 5-23 [NAME] didnt reove cart this morning, I was nervous, panic And the count hAS BEEN OFF FOR 2 DAYS THE CARD WAS REMOVED 2 DAYS AGO , the last signed out narc on the card was 7-30-19 and was . Process of narc shift change. We were counting them wrong D/T fentanyl boxes 2 and was counting. at what point do u count the cards and put on the card sheet, typically the cards match we look to see if something has been forgotten to add or delete cards. I realized that the card count was off when state ask about cards. On friday-trouble this weekend call MD for ER RX of narco.MD was called on Sat. call in partial script, 3 days worth of pills flow sheet the narc was not taken off of card sheet on tuesday. and card count was incorrect for 2 days. Education for all nurses inserviced to stop what they are doing if there is a narc count wrong. then everyone will count carts. 1 month ago audit count audit completed.[NAME] Stone RN SDC, will inservice this evening . roaster to ensure that all employess have been inserviced. Anytime a decripency in count lock cart and get ADMIN to investigate hat happened and do an investigation . [NAME] get UM together bring narc to me log in book ensure that it was correct, the DON/ADON have to open box to narc together Cart locking always keep locked, if employee in eye view of cart is it ok to keep unlocked=NO Narc folder in DON office count that DON/ADON have to sign when narcs are destroyed. [DATE] 09:33 AM [NAME] Rowe ADMIN- Narc are always double locked 2 key holders. Count for the nurses fo a manual count, theyb sign that the count is correct. How do you ensur that staff are doing we take it to QI, orientation, competency fairs throughout the year. Do you reviw audits review in QI, DON brings records to QI, never had any problems with count. Card count sysytem signature tool not a system is not a tool. [NAME] Stone SDC RN x2018.Completes all in-service in blg December was all in-service, di all nurses attended, problem in December whole in count in-service on how to count correctly, no issues with the narcotic cards.If there is an decrepency let the supervisor know statrt a inservice. should sign off if incorrect and you did not see card. [NAME]- LPN [DATE] 09:48 AM process of card being removed take top off , write down meds empty then sign, can have a nurse sign if avaialbel. Policy stated that you have to havee 2 nurses to sign. Did not see that narc card and signed and I should not have sign that I did that . Did that d/t being nervous. If I did not see next time I would not do this. Yesterday I was inserviced on process and have been inserviced in the past. I saw that the sheet was accounted for and every med was accounted for. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to insure controlled medication records accounted for per facility procedures to prevent diversion. Review of a Narcotic Flow Sheet revealed no witness signature for the removal of a card. In addition, review of the narcotic sheet count revealed the count was incorrect for two (2) days. The findings include: Review of facility policy Medication Storage-Controlled Medication Storage, dated [DATE], revealed medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and record keeping. Review of facility In-Service: [DATE], revealed the facility requirement for staff to note medication removed, reason, and both nursing staff signatures and ending cart balance. Review of a Narcotic Flow Sheet, revealed the entry on [DATE] for the night shift indicated the removal of the medication card for Gabapentin one hundred (100) milligrams. The entry contained the signature of only one (1) staff member, with the signature line for the second staff member blank. An audit of the narcotic cards in the lock box, on [DATE], revealed a discrepancy in the count of the narcotic card sheets. The audit revealed an incorrect count of the medication cards led to a discrepancy on the Narcotic Flow Sheet in which staff incorrectly documented the number of cards. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:01 PM, revealed two (2) nurses should sign-off when removing controlled substance cards from the available supply. LPN #1 stated a nurse removed the controlled substance and signed the record. That nurse then showed the card to a second nurse who then signed the record. LPN #1 stated the facility provided an in-service to staff regarding controlled substance card count. Continued interview with LPN #1 revealed the on-coming nurse and the off-going nurse failed to count the narcotic count sheets correctly for two (2) days. LPN #1 stated staff were incorrectly counting the boxes of fentanyl, by counting the boxes of fentanyl as two (2) separate containers as opposed to one (1). LPN #1 stated the facility audited narcotics to insure there was no diversion of these medications from the facility. Interview with the Director of Nursing (DON), on [DATE] at 4:02 PM, revealed two (2) staff insured narcotic medication counts were correct and signed the sheet as a record. The DON stated the facility conducted an audit/count of controlled substances in [DATE], and found no discrepancies. Interview with the Administrator, on [DATE] at 9:33 AM, revealed the facility secured controlled medications by requiring two (2) nursing staff to perform a manual count of controlled substances and sign-off on the counts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy, Psychotropic Medication, not dated, revealed the facility would make every effort to comply with state and federal regulations related to the use of psychotropic medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks, and/or benefits. The policy revealed nursing staff was responsible for reviewing the use of the medication with the physician and the Interdisciplinary Team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use. Review of the clinical record revealed the facility admitted Resident #54 on 12/01/15, with diagnoses to include Chronic Kidney Disease, Hemiplegia of Right Dominant Side, Adult Failure to Thrive, Dementia, and Major Depressive Disorder. Review of Resident #54's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) out of fifteen (15) and determined he/she was interviewable. The facility assessed the resident had no potential indicators of Psychosis and had not displayed behavioral symptoms. Per the MDS, the resident received Antipsychotic medication for the last seven (7) days. Review of the Physician Orders, dated May 2018, for Resident #54 revealed an order for Quetiapine ER (Seroquel) 50 milligram (mg) at bedtime for diagnosis of Bipolar Disorder, dated 12/14/17. Observation, on 05/15/18 at 12:52 PM, revealed Resident #54 in bed with his/her eyes closed and a lunch tray on the over the bed table. Interview with Resident #54, on 05/15/18 at 1:30 PM, revealed he/she had been sleepier the last few days. The resident was in bed with an uneaten lunch tray at the bedside. At 2:51 PM, the resident was in bed. Observation, on 05/16/18 at 9:43 AM, revealed Resident #54 in bed and the breakfast tray was on the over the bed table. At 3:09 PM, he/she remained in bed. Review of Resident #54's Care Plan, dated 03/23/16, revealed the resident was at risk for signs and symptoms of adverse effects of psychotropic medication with a goal to be free from signs and symptoms of adverse effects. The interventions included observe for signs and symptoms of drug related decline in appetite. Report to the Physician any negative outcomes associated with use of the drug. Review of the Progress Notes, dated 05/05/18 at 8:53 AM, revealed Resident #54 refused the evening dose of Seroquel, had reportedly refused all week and stated he/she was not going to take the medication again because it made him/her sleepy. Review of the Medication Administration Record (MAR), dated May 2018, revealed Resident #54 refused the 8:00 PM dose of Seroquel ER 50 mg 05/05/18 through 05/14/18. Further review of Physician Orders revealed a faxed order, dated 05/07/18, to discontinue Seroquel 50 mg if the resident exhibited no behaviors. Review of Resident #54's Behavior Monitoring revealed the resident exhibited no behaviors 01/03/18 through 05/15/18. However, review of Progress Notes, dated 05/14/18, revealed the administration time for Seroquel was changed from 8:00 PM to 8:00 AM and further review of the MAR revealed Seroquel ER 50 mg was administered to the resident at 8:00 AM on 05/15/18 and 05/16/18. Review of Resident #54's MAR, dated 02/01/18 through 05/15/18, for Antipsychotic Side Effect Monitoring revealed the resident exhibited no side effects related to the use of antipsychotics, including drowsiness and loss of appetite. Interview, on 05/17/18 at 10:01 AM, with CNA #5, revealed Resident #54 did not get out of bed much and slept a lot. The CNA stated the resident sometimes refused to take a shower, but she had not witnessed any behaviors. Interview with RN #4, on 05/17/18 at 10:25 AM, revealed resident behaviors should be documented in the behavior notes and medication side effects in the MAR. The RN stated Resident #54 slept a lot but she had not notified the physician because she thought it was part of his/her personality. Interview with RN #5, on 05/17/18 at 1:10 PM, revealed she requested a change of Resident #54's Seroquel administration time from bedtime to 8:00 AM because the resident reported the medication made him/her sleepy. The RN stated she had not noticed any recent changes in the resident's sleep patterns. Interview with the Assistant Director of Nursing (ADON), on 05/17/18 at 11:35 AM, revealed Resident #54 had decreased appetite and was in bed more since the last Gradual Dose Reduction (GDR), but she had not notified the physician. The ADON revealed the purpose of monitoring for side effects of psychoactive medication was to ensure the appropriateness of the medication. According to the ADON, there was no behavior or side effects documented in the clinical record to support the use or discontinuation of Resident #54's Seroquel. She further revealed the psychotropic medication care plan related to monitoring for side effects was not followed. Interview, on 05/17/18 at 3:30 PM, with the DON revealed she had not identified any concerns regarding monitoring for side effects of psychoactive medications. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for two (2) of twenty-two (22) sampled residents, Resident #18 and #54. Staff failed to provide care consistent with the care plan, which resulted in facial bruising to Resident #18 and Resident #54 was not monitored for side effects of psychotropic medication according to the care plan. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed the Comprehensive Care Plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The nurse/Interdisciplinary team developed and maintained a comprehensive care plan for each resident that would identify the highest level of functioning the resident might be expected to attain. Care plan interventions were to be implemented to reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. The policy stated care plans were ongoing and would be revised as information about the resident and the resident's condition changed. 1. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/01/12. The resident had diagnoses of Heart Failure, Pneumonia, Alzheimer's Disease, Cerebrovascular Accident, Hemiplegia/Hemiparesis, Seizure/Epilepsy Disorder, Psychotic Disorder, Chronic Lung Disease, Mood Disorder, and Dementia with Behaviors. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) and determined the resident not interviewable. Per the MDS, the resident had clear speech; usually had the ability to express ideas and wants; and had the ability to understand others. The facility assessed the resident displayed behaviors not directed toward others for one (1) to three (3) days. Observation of Resident #18, on 05/15/18 at 10:55 AM, revealed him/her in a reclined chair on the 200 Hall with a black/purple discoloration around the right periorbital (eye) area. Interview with Resident #18, on 05/15/18 at 10:55 AM, revealed two (2) Certified Nursing Assistants (CNA) had approached him/her during the night, and woke him/her out of a deep sleep to change his/her dirty brief. The resident stated when the CNAs turned him/her over to his/her side, it hurt because he/she had arthritis. The resident continued to state the CNAs would not listen to him/her when he/she tried to tell them how to turn him/her without hurting him/her. Resident #18 stated the CNAs hit him/her in the eye with something during the time they were changing his/her brief. Review of Resident #18's Progress Notes, dated 05/15/18 at 4:07 AM, revealed Registered Nurse (RN) #1 documented when the CNAs went into Resident #18's room to change a soiled brief, the resident began hollering for help. After explaining they were there to assist with peri-care, the resident cursed them and slapped one CNA on the mouth. Appropriate behaviors encouraged and the resident was left in a calm, quiet environment. Review of a Nursing Assessment, signed and dated by RN #1 on 05/15/18 at 6:15 AM, revealed while staff was changing Resident #18's soiled brief, the resident became combative and slapped staff on their face, with arms flailing. Later, bruising was noted under the resident's right eye. The CNA stated when she turned the resident she noticed his/her face was close to a bed remote hanging on a turning bar, but was unsure if the resident hit his/her head on the turning bar. Review of Resident #18's Comprehensive Care Plan, dated 09/02/17, revealed the resident was at risk for injury or harm related to potential misunderstandings that might arise secondary to his/her cognitive impairment related to the diagnoses of Psychosis, Alzheimer Dementia, and Mood Disorder. The goal was the resident would make routine daily decisions with cues/supervision regarding activities of daily living and participate with care. Interventions included if the resident was restless or agitated, re-approach later. Interview with CNA #2, on 05/16/18 at 11:35 AM, via telephone revealed she and CNA #3 approached Resident #18 during the early morning of 05/15/18 and informed the resident they came to change his/her brief. She stated they turned the resident to his/her right side and the resident proceeded to push his/her body away by pushing against the bed's grab bar and then the resident gave in and hit his/her head on the turn bar. She stated the resident was hollering to quit, but they continued to change the brief and wipe excrement off the resident's skin. The CNA stated she should have stopped changing the resident when he/she said too, and notified the resident's nurse. She stated she had been educated on the care of the Dementia residents and knew to leave agitated residents alone and try to re-attempt care after a brief time. Interview with CNA #3, on 05/16/18 at 1:58 PM, via telephone revealed she and CNA #2 went into Resident #18's room on 05/15/18 at around 3:40 AM to change the resident's brief and to turn him/her. She stated the resident used the grab bar to push himself/herself away from her as she was pulling him/her. It was then the resident rolled into the remote on his/her bed. She stated it was normal for the resident to have behaviors but it would have made more sense to stop trying to change the resident's brief and notify the resident's nurse. CNA #3 stated she noticed bruising on the resident's right eye at 5:40 AM, and immediately notified the resident's nurse. Review of Educational Training revealed CNA #2 and #3 received training and education on the care of residents with Dementia in 2018. Interview with CNA #4, on 05/16/18 at 2:33 PM, revealed she would go to the nurse if she encountered behaviors with any resident. She stated she had been educated to stop providing care to a resident when the resident was stating to stop or quit as long as the resident was safe, and it was never acceptable to force a resident to do anything. Interview with RN #1 via telephone, on 05/17/18 at 10:00 AM, revealed she was informed about Resident #18's bruised eye area around 6:00 AM the morning of 05/15/18 by a CNA. She stated staff told her the resident might have hit his/her eye area on a remote when he/she became disruptive during a brief change. The nurse stated the CNAs should have notified her when the resident became disruptive with the brief change, gave the resident a little time, and then went back and re-approached him/her later, which was an intervention often utilized with residents who had Dementia. The nurse stated the resident did have some confusion and sometimes refused medications, but with re-assurance and re-education, he/she generally became less agitated. She stated it was not very often the resident displayed behaviors while she provided care to him/her. She stated the resident was a high risk for bleeding due to his/her medications (Clopidogrel to reduce blood clot risk) which could have caused increased bleeding. She stated resident care plans helped staff better care for each individual resident. Interview with RN #2, on 05/16/18 at 3:00 PM, revealed she was familiar with Resident #18 and the resident's plan of care. She stated if the resident directed staff to stop or quit, staff should have re-assured the resident and/or re-approached the resident a while later as directed by the care plan. The RN stated Resident #18's behaviors would escalate when staff went against his/her requests, as the resident was not always confused. Interview with the Unit Manager, on 05/16/18 at 10:30 AM, revealed Resident #18's care plan indicated staff should re-approach the resident later when he/she displayed negative behaviors or specific requests, and the nurse should have been notified right away when the resident started having behaviors. Interview with the Director of Nursing (DON), on 05/16/18 at 10:30 AM, revealed the CNAs had received training related to how to effectively deal with and manage residents with behaviors and a Dementia diagnosis. She stated the CNAs should have stopped what they were doing with Resident #18, notified the nurse immediately, and re-approached the resident again after a short period of time.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide care following professional standards for three (3) of twenty-two (22) sampled residents, Resident #11, #24, and #84. Observation revealed staff did not verify Gastrostomy tube (G-tube) placement prior to flushing the tube for Resident #24, and staff did not obtain accu-checks per the facility's guidelines for Resident #11 and #84. The findings include: Review of the facility's Gastrostomy Feeding Competency, dated 10/02/15, revealed guideline step #7 stated to verify tube placement. Review of the facility's Capillary Blood Glucose Level Competency, dated 06/01/15, revealed guideline step #8 stated to obtain a blood sample by using a sterile lancet (a spring-loaded or manual lancet). Discard the first drop of blood if alcohol was used to clean the fingertips because alcohol might alter the results. Observation of Resident #24, on 05/16/18 at 10:50 AM, revealed Licensed Practical Nurse (LPN) #2 flushed the resident's G-tube with 60 cubic centimeters (cc) of water without checking for placement prior to flushing. Observation of Resident #84, on 05/16/18 at 10:35 AM, revealed LPN #2 performed an accu-check on the resident. The nurse cleaned the resident's finger with an alcohol prep, stuck the resident's finger, and did not discard the first sample of blood. Observation of Resident #11, on 05/17/18 at 11:00 AM, revealed LPN #1 performed an accu-check using an alcohol prep to clean the resident's finger and the proceeded to use the first sample of blood for the reading. Interview with LPN #2, on 05/17/18 at 2:00 PM, revealed she was not trained to discard the first drop of blood if alcohol was used to collect a sample for an accu-check. LPN #2 stated she knew when she stepped out of Resident #24 room; she forgot to check for G-tube placement. She stated it was important to check for placement to make sure medications and flushes went to the right place, preventing possible infection. Interview with Registered Nurse (RN) #4, on 05/17/18 at 2:10 PM, revealed it was important to wipe away the first drop of blood when using an alcohol prep for accu-checks because alcohol interfered with the accuracy of the sample. RN #4 also stated it was important to check for placement of a G-tube to make sure medications went into the right place. Interview with RN #3, on 05/17/18 at 2:20 PM, revealed it was important to check placement of a G-tube to prevent medication or flushes from going into interstitial space, which could cause infection. RN #3 also stated the first drop of blood should be discarded due to alcohol tainting the accuracy of the accu-check reading, which could possibly cause harm to a resident because of an inaccurate result. Interview with RN #2, on 05/17/18 at 2:30 PM, revealed she discarded the first sample of blood after cleaning fingers with alcohol to ensure an accurate reading. RN #2 stated checking for G-tube placement was important to prevent medication or flushes from going in between tissues and causing infection. Interview with the Director of Nursing (DON), on 05/17/18 at 2:40 PM, revealed it was important to check for G-tube placement because it would be very detrimental to a resident if medications or flushes entered the wrong space, as it could possibly harm a resident. The DON also stated staff should always discard the first drop of blood when using an alcohol wipe to maintain accuracy of the sample.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain a hazard free environment for one (1) of twenty-two (22) sampled residents, Resident #18. Staff failed to implement care plan interventions while providing care, which resulted in facial bruising to the resident. The findings include: Review of the facility's policy, Dementia Care, revised 06/28/17, revealed the facility was to enhance the quality of life and care for residents with Dementia with a goal to provide an environment that was peaceful, calm, safe, and accepting thus enabling residents to reach their full potential. The policy continued to state the focus of care was directed toward what the resident could do so their optimal physical functioning, enjoyment of life, and self-esteem was maintained. Individualized approaches to care would be utilized to focus on the resident's needs in an attempt to reduce behavioral expressions of distress. The aims of care followed included promotion and maintenance of a safe environment, practice of minimal interaction with residents whom were highly agitated or who experienced an altered behavior in their responses, and respect of the personal space of each resident. Review of the facility's Management of Aggressive Behavior Tool, dated 06/01/15, revealed the purpose was to protect the residents from injuring themselves or others and to bring aggressive incidents and occurrences under control. The guideline steps included allowing the aggressive resident space, avoid standing too close, surrounding, or touching the aggressive resident, and to take a calm approach. Observation of Resident #18, on 05/15/18 at 10:55 AM, revealed the resident sitting in a reclined chair on the 200 Hall. The resident had a black/purple discoloration around the right eye. Interview, on 05/15/18 at 10:55 AM, with Resident #18 during the observation revealed two (2) Certified Nursing Assistants (CNA) came into his/her room during the night and woke him/her out of a deep sleep to change his/her brief. The resident stated when the CNAs turned him/her over to his/her side, it hurt as he/she had arthritis. Per the resident, the CNAs would not listen to him/her when he/she tried to tell them how to turn him/her without it hurting. Resident #18 revealed the CNAs hit him/her in the eye with something during the time they were changing his/her brief and he/she would hit anyone who tried to hurt him/her. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/01/12, and had multiple diagnoses, which included Alzheimer's Disease, Hemiplegia/Hemiparesis, and Dementia with Behaviors. Review of the Quarterly Minimum Data Set, dated [DATE], revealed the facility determined the resident had clear speech; usually had the ability to express ideas and wants; and had the ability to understand others. The facility assessed the resident displayed behaviors not directed toward others for one (1) to three (3) days. Review of Progress Notes, dated 05/15/18 at 4:07 AM, revealed CNAs went into Resident #18's room to change a soiled brief; the resident began hollering for help. After explaining staff was there to assist with peri-care, the resident cursed them and slapped a CNA on the mouth. Appropriate behaviors were encouraged and the resident was left in a calm, quiet environment. Review of a Nursing Assessment, dated 05/15/18 at 6:15 AM, revealed Resident #18 became combative and slapped staff on the face, with arms flailing, while changing the resident's soiled brief. Bruising was noted under the resident's right eye later. The CNA said when she turned the resident, she noticed his/her face was close to a bed remote hanging on a turning bar, but she was unsure if the resident hit his/her head on the turning bar. Review of Resident #18's Care Plan, dated 09/02/17, revealed a risk for injury or harm related to potential misunderstandings that might arise secondary to the resident's cognitive impairment and interventions listed included if the resident was restless or agitated, re-approach later. Interview via telephone, on 05/16/18 at 11:35 AM, with CNA #2 revealed she and CNA #3 entered Resident #18's room early in the morning on 05/15/18 to change his/her brief. She stated while the resident was turned to his/her right side, he/she pushed away by pushing against the grab bar on the bed and when the resident gave in, he/she hit his/her head on the turn bar. She stated the resident yelled to stop but she and CNA #3 continued to change the brief. She revealed they should have stopped when the resident said too because she had been trained to leave agitated residents alone and re-attempt care after a brief period of time. Interview via telephone, on 05/16/18 at 1:58 PM, with CNA #3 revealed she went with CNA #2 to change Resident #18's brief and turn him/her on 05/15/18 at around 3:40 AM. She stated the resident pushed himself/herself away from her as she had was turning him/her and the resident rolled into the remote on the bed. She stated she and CNA #2 should have stopped trying to change the resident's brief and notified the nurse. CNA #3 stated she immediately notified the resident's nurse when she noticed bruising on the resident's right eye at 5:40 AM. Interview, on 05/16/18 at 2:33 PM, with CNA #4 revealed when providing care, it was never acceptable to force a resident to do anything if the resident said to stop, per the education she received. She stated she would notify the nurse if she encountered behaviors with a resident. Interview via telephone, on 05/17/18 at 10:00 AM, with Registered Nurse (RN) #1 revealed around 6:00 AM on 05/15/18, staff informed her about Resident #18's bruised eye area that happened when the resident became disruptive during a brief change and possibly hit his/her eye on a remote. RN #1 stated when the resident became disruptive with the brief change, staff should have notified her, and gave the resident a little time and then re-approached him/her later. She stated that was an intervention staff utilized with residents with Dementia. Per interview, the resident had some confusion and became less agitated with re-assurance and re-education. RN #1 stated the resident was a high risk for bleeding due to his/her medications (Clopidogrel to reduce blood clot risk) which could have caused increased bleeding. Interview, on 05/16/18 at 3:00 PM, with RN #2 revealed if Resident #18 told staff to stop, staff should have re-assured the resident, and/or re-approached the resident a while later. According to RN #2, Resident #18 was not always confused and his/her behaviors would escalate if staff went against his/her requests. Interview, on 05/16/18 at 10:30 AM, with the Director of Nursing revealed the nursing assistants should have stopped what they were doing and notified the nurse, and re-approached Resident #18 after a short period of time. She stated the CNAs were trained on how to manage residents with behaviors and diagnosed with Dementia. Review of Educational Training revealed CNA #2 and #3 received training and education on the care of residents with Dementia in 2018, as well as Accident Prevention and Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide appropriate care and services to one (1) of twenty-two (22) sampled residents, Resident #18. The resident was diagnosed with Dementia and staff failed to provide care consistent with the plan of care, which resulted in facial bruising to the resident. The findings include: Review of the facility's Dementia Care Policy, revised 06/28/17, revealed it was the policy of the facility to enhance the quality of life and care for residents with Dementia and the goal for the residents with dementia was to provide an environment that was peaceful, calm, safe, and accepting, thus enabling them to reach their full potential. Individualized approaches to care would be utilized to focus on the resident's needs in an attempt to reduce behavioral expressions of distress. Review of the facility's Management of Aggressive Behavior Tool, dated 06/01/15, revealed the purpose was to protect the residents from injuring themselves or others, and to bring aggressive incidents and occurrences under control by allowing the aggressive resident space, avoid standing too close, surrounding, or touching the aggressive resident, and to take a calm approach. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/01/12 and had multiple diagnoses that included Alzheimer's disease and Dementia with Behaviors. Per the Quarterly Minimum Data Set, dated [DATE], the facility assessed the resident had clear speech, usually had the ability to express ideas and wants, and had the ability to understand others. The facility determined the resident displayed behaviors not directed toward others that occurred one (1) to three (3) days. Interview with Resident #18, on 05/15/18 at 10:55 AM, revealed two (2) Certified Nursing Assistants (CNA) woke him/her out of a deep sleep to change his/her brief. The resident stated he/she had arthritis and it hurt when they turned him/her over to his/her side. Resident #18 continued to state he/she tried to tell the CNAs how to turn him/her with it hurting, but they would not listen. According to the resident, the CNAs hit him in the eye with something during the brief change. Observation of the resident during the interview revealed he/she had a black/purple discoloration around the right eye. Review of Resident #18's Progress Notes, dated 05/15/18 at 4:07 AM, revealed when the CNAs went into Resident #18's room to change a soiled brief, the resident began hollering for help. After explaining they were there to assist with peri-care, the resident cursed them and slapped one CNA on the mouth. Appropriate behaviors encouraged and the resident was left in a calm, quiet environment. Review of a Nursing Assessment, dated 05/15/18 at 6:15 AM, revealed Registered Nurse (RN) #1 documented while staff was changing Resident #18's soiled brief, the resident became combative and slapped staff on the face, while arms flailing. Later, staff noticed bruising under the resident's right eye. The CNA stated when she turned the resident she noticed his/her face was close to a bed remote hanging on a turning bar, but was unsure if the resident hit his/her head on the turning bar. Review of Resident #18's Care Plan, dated 09/02/17, revealed a potential alteration in safety and well-being and the resident was at risk for injury or harm related to potential misunderstandings that might arise secondary to his/her diagnoses of Psychosis, Alzheimer's Dementia, and Mood Disorder. The goal was for the resident to make routine daily decisions with cues/supervision regarding activities of daily living and participate with care. Interventions included to re-approach the resident later if the resident was restless or agitated. Interview with CNA #2 via telephone, on 05/16/18 at 11:35 AM, revealed on 05/15/18 in the early morning, she and CNA #3 approached Resident #18 and informed him/her they were going to change his/her brief. She stated the resident was turned to his/her right side and was pushing his/her body away by pushing against the bed grab bar. She stated the resident gave in and hit his/her head on the turn bar. According to CNA #2, the resident hollered to quit, but they continued to change the brief and clean the resident's skin; however, the CNA stated she should have stopped when the resident said too, and notified the nurse. She stated Dementia training instructed staff to leave agitated residents alone and try to re-attempt care after a brief period. Interview with CNA #3 via telephone, on 05/16/18 at 1:58 PM, revealed she and CNA #2 went into Resident #18's room on 05/15/18 at around 3:40 AM to change the resident's brief and to turn him/her. She stated the resident used the grab bar to push himself/herself away from her as she turned him/her and the resident rolled into the remote on his/her bed. The CNA stated the resident usually displayed behaviors, and they should have stop trying to change the resident's brief and notified the nurse. CNA #3 stated she noticed bruising on the resident's right eye at 5:40 AM and immediately notified the resident's nurse. Review of educational training revealed CNA #2 and CNA #3 received Dementia Training Behavior Management in 2018. Interview with CNA #4, on 05/16/18 at 2:33 PM, revealed she would always go to the nurse if she encountered behaviors with any resident. She stated she had been educated to immediately stop providing care to a resident when the resident was stating to stop or quit (as long as the resident was safe) and it was never acceptable to force a resident to do anything. Interview with Restorative Aide #1, on 05/17/18 at 10:10 AM, revealed she frequently cared for Resident #18 during the resident's restorative care sessions. She stated the resident could become agitated and combative and it was appropriate for staff to leave him/her alone and re-approach at another time. She stated the resident sometimes complained of pain with treatment and would state to stop. The Restorative Aide stated staff would halt therapy, resumed if the resident agreed, but if the resident became uncooperative, staff would then report his/her behaviors to the resident's nurse. She stated Resident #18 was mostly cognitively aware and appropriate when she worked with him/her. She stated by continuing to perform a task to a resident when the resident had stated stop was against resident rights, and stated staff had been trained multiple times on resident rights. Interview with RN #1 via telephone, on 05/17/18 at 10:00 AM, revealed the CNA reported to her about Resident #18's bruised eye around 6:00 AM the morning of 05/15/18, that occurred during a brief change when he/she became disruptive and might have hit his/her eye area on a remote. The nurse stated the CNAs should have notified her when the resident became disruptive, and gave him/her a little time and then went back and re-approached him/her later, which was an intervention often utilized with residents who had Dementia. RN #1 stated the resident had some confusion, but with re-assurance and re-education, he/she generally became less agitated. Interview with RN #2, on 05/16/18 at 3:00 PM, revealed she was familiar with Resident #18 and if the resident directed staff to stop, or quit, staff should have re-assured the resident and/or re-approached the resident a while later. The RN stated Resident #18's behaviors would escalate when staff went against his/her requests, as the resident was not always confused. Interview with the Unit Manager, on 05/16/18 at 10:30 AM, revealed the care plan for Resident #18 indicated the resident should have been re-approached later when he/she displayed behaviors. She stated the nurse should have been notified right away when the resident started having behaviors. Interview with the Director of Nursing, on 05/16/18 at 10:30 AM, revealed the CNAs were trained how to effectively deal and manage residents with behaviors and a Dementia diagnosis. She stated the CNAs should have stopped what they were doing with Resident #18, notified the nurse immediately, and re-approached the resident again after a short period of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents, Resident #54, was free from unnecessary medications. The facility failed to discontinue Resident #54's Seroquel (antipsychotic) as ordered by the physician and failed to monitor for side effects of the medication. The findings include: Review of the facility's policy, Behavior Management, reviewed September 2016, revealed a Behavior Management Care Plan (BMP) would be developed by the Social Worker/designee for any resident exhibiting a behavior that interfered with the Plan of Care. The policy revealed the BMP would identify appropriate interventions to manage identified behavior(s) and include measurable goals related to the behavior. According to the policy, a copy of the BMP would be kept in a BMP Manual at each nurses' station and in a BMP Manual in the Social Services Director's office. Review of the facility's policy, Target Behavior Management, reviewed 11/23/15, revealed the Interdisciplinary team (IDT) would review residents with target behaviors at the weekly At Risk meeting and complete the Psychotropic Review/Behavior Meeting form. The policy further revealed the IDT would review residents' psychotropic medications to determine if a Gradual Dose Reduction (GDR) was indicated and complete the Psychotropic Review Committee Recommendation form. The form would then be reviewed and signed by Psychiatric Services and the Medical Director/Physician. Review of the facility's policy, Psychotropic Medication, not dated, revealed the facility would make every effort to comply with state and federal regulations related to the use of psychotropic medications in the long-term care facility to include regular review for continue need, appropriate dosage, side effects, risks, and/or benefits. Efforts to reduce dosage or discontinue use of psychotropic mediations would be ongoing, as appropriate, for the clinical situation. The policy revealed nursing staff was responsible for reviewing the use of the medication with the physician and the IDT team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use. Review of Resident #54's clinical record revealed the facility admitted the resident on 12/01/15, with multiple diagnoses that included Dementia and Major Depressive Disorder. Review of the Quarterly Minimum Data Set, dated [DATE], revealed the facility assessed the resident had no potential indicators of Psychosis, had not displayed behavioral symptoms, and had received Antipsychotic medication for the last seven (7) days. The facility assessed Resident #54 with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined he/she was interviewable. Observation, on 05/15/18 at 12:52 PM, revealed Resident #54 in bed with his/her eyes closed and a lunch tray on the over the bed table. Interview with Resident #54, on 05/15/18 at 1:30 PM, revealed he/she had been sleepier in the last few days. Observation revealed the resident in bed and an uneaten lunch tray at the bedside. At 2:51 PM, the resident was in bed. Observation, on 05/16/18 at 9:43 AM, revealed Resident #54 in bed. A breakfast tray was on the over the bed table. At 3:09 PM, the resident remained in bed. Review of Resident #54's Physician Orders, for May 2018, revealed and ordered dated 12/14/17, for Quetiapine ER (Seroquel) 50 milligram (mg) at bedtime for diagnosis of Bipolar Disorder. Review of the Progress notes, dated 05/05/18 at 8:53 AM, revealed Resident #54 refused the evening dose of Seroquel, had reportedly refused all week, and stated he/she was not going to take the medication again because it made him/her sleepy. Review of Resident #54's Medication Administration Record (MAR), dated May 2018, revealed the resident refused the 8:00 PM dose of Seroquel ER 50 mg 05/05/18 through 05/14/18. Further review of Physician Orders revealed a faxed order, dated 05/07/18, to discontinue Seroquel 50 mg if the resident exhibited no behaviors. Review of the Treatment Notes for Resident #54's Behavior Monitoring revealed the resident exhibited no behaviors 01/03/18 through 05/15/18. However, review of Resident #54's Progress notes, dated 05/14/18, revealed the administration time for Seroquel was changed from 8:00 PM to 8:00 AM. Further review of the MAR revealed staff administered Seroquel ER 50 mg at 8:00 AM on 05/15/18 and 05/16/18 to the resident. Review of the MAR, dated 02/01/18 through 05/15/18, for Antipsychotic Side Effect Monitoring revealed staff documented Resident #54 exhibited no side effects related to the use of antipsychotics, including drowsiness and loss of appetite. Interview with CNA #5, on 05/17/18 at 10:01 AM, revealed Resident #54 did not get out of bed much and slept a lot. The CNA revealed she had not witnessed any behaviors other than the resident sometimes refused to take a shower. Interview with Registered Nurse (RN) #4, on 05/17/18 at 10:25 AM, revealed Resident #54 had a history of cursing at staff and yelling at his/her roommate. She stated resident behaviors should be documented in the behavior notes and medication side effects in the MAR. RN #4 stated the resident slept a lot but she had not notified the physician because she thought it was part of his/her personality. Interview with RN #5, on 05/17/18 at 1:10 PM, revealed she requested a change of Resident #54's Seroquel administration time to 8:00 AM related to the his/her refusal of the 8:00 PM dose. The RN stated she requested the change because the resident reported the medication made him/her sleepy. She further stated she was not aware of the faxed physician's order to discontinue the Seroquel. Interview with the Social Services Director (SSD), on 05/17/18 at 1:45 PM, revealed he was responsible for initiating and revising resident Behavior Monitoring Plans (BMP) and ensuring the BMP manuals were current. The SSD stated it was important to ensure the BMP was in the manuals so staff was aware of a resident's target behaviors, interventions for management of the behaviors, and any progress made towards the behavioral goal. He further stated the manuals should be current in order to track the behaviors and the need for psychotropic medications. The SSD revealed Resident #54 did not have a BMP in the SSD's manual. Review of the BMP manual located at the Magnolia nurses' station revealed there was no BMP for Resident #54. Interview with the Assistant Director of Nursing (ADON), on 05/17/18 at 11:35 AM, revealed Resident #54 had a decreased appetite and had been in bed more since the last GDR, but she had not notified the physician. She stated the resident used to get out of bed in the evenings, but now spent 75% of his/her time in bed. The ADON revealed the purpose of monitoring for side effects of psychoactive medication was to ensure the appropriateness of the medication and stated there was no documentation to support the use or discontinuation of Resident #54's Seroquel. The nurse revealed she did not audit the clinical record or the MARs for accuracy and stated the SSD was responsible for monitoring behaviors. She further stated she was not aware of the physician order on 05/07/18 to discontinue Resident #54's Seroquel. Interview with the Director of Nursing (DON), on 05/17/18 at 3:30 PM, revealed she had identified concerns with the SSD's ability to handle the facility's behavior program. She stated it was important to ensure Resident #54 was in the BMP manual so that staff knew how to care for and address potential behaviors. The DON stated she was not aware of the physician order to discontinue Resident #54's Seroquel.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure controlled substances, that required refrigeration, were stored within a locked, permanently affixed compartment within the refrigerator in one (1) of two (2) medication rooms. The findings include: Review of the facility's policy, Controlled Medication Storage, dated November 2017, revealed controlled medications requiring refrigeration were stored within a locked, permanently affixed box within the refrigerator. Observation of the Dogwood Medication Room, on 05/17/18, at 1:40 PM, revealed the medication refrigerator contained a small emergency narcotic (controlled substance) container not secured within a locked permanently affixed box. There were six (6) tablets of Ativan 0.5 milligram (mg), six (6) tablets of Hydrocodone/Acetaminophen 5/325 mg, six (6) tablets of Hydrocodone/Acetaminophen 7.5/325 mg, six (6) tablets of Oxycodone/Acetaminophen 5/325 mg, two (2) vials of Morphine 10 mg, and two (2) vials of Ativan 2 mg in the container. There was a chain in the refrigerator, attached to the refrigerator, without any type of box attached to it. Interview with Licensed Practical Nurse #2, on 05/17/18 at 2:00 PM, revealed the chain had always been in the refrigerator but since she had been working there, nothing had ever been attached to it. She stated she thought a locked box should be attached to the chain for storage of narcotic medication, but it never had one attached. Interview with Registered Nurse #4, on 05/17/18 at 2:10 PM, revealed refrigerated narcotics were usually kept in a locked secured box in the refrigerator, but the unit did not have one. Interview with the Director of Nursing (DON), on 05/17/18 at 2:40 PM, revealed she was not aware the narcotic box was not secured in the refrigerator. The DON stated she had many concerns regarding the narcotic box not being secured. One concern was that the box was so small; any nurse could place it in a purse and walk out of the facility with it, unnoticed. She stated not having the narcotic box secured properly could cause a problem and the facility should be thinking of safety first.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure biohazard materials were not stored with medications in one (1) of two (2) medication rooms. The findings include: Review of the facility's Infection Control Policy, dated July 2014, revealed the facility's infection control practices were intended to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public, and to help prevent and manage transmission of diseases and infections. Observation of the Dogwood Medication room, on 05/17/18, at 1:40 PM, revealed the bottom drawer in the medication refrigerator contained a red biohazard bag. The refrigerator contained several vials of Flu, Pneumonia, and Hepatitis B vaccines for resident use. There were resident insulin vials and an emergency use narcotic box that contained several medications for resident use. Interview with Licensed Practical Nurse #2, on 05/17/18 at 2:00 PM, revealed staff placed lab specimens that needed to be refrigerated, such as urine, in the biohazard bag until lab staff picked up the specimens. The nurse stated cross contamination could occur if labs specimens were housed with medications. Interview with Registered Nurse #3, on 05/17/18 at 2:20 PM, revealed the facility used the bottom of the refrigerator for urine specimens that needed to be refrigerator until lab staff came to collect, which could cause cross contamination making a resident sick. Interview with the Director of Nursing (DON), on 05/17/18 at 2:40 PM, revealed staff should not store labs in a medication refrigerator and she was not sure why biohazard bags were in the bottom of the refrigerator. The DON stated storing labs in the same refrigerator as medications was not best nursing practice.