Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement a baseline person-centered care plan for one (1) of twenty-four (24) sampled residents (Resident #61). Review of the resident's care plan for activities was incomplete after seven (7) weeks. The findings include: Review of the facility's policy titled, Base Line Care Plan, not dated, revealed the facility must develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care. Further review revealed the base line care plan must be developed within forty-eight (48) hours of a resident's admission, and it was to be a continuous changing document as changes occurred with the resident's plan of care. Additional review revealed there were thirty-two (32) care areas listed to be considered for care planning, including Activities. The policy further stated that each area listed should include specific interventions and should include the current date for the problem identified and initiated. The policy additionally stated that the admission care plan was to serve as a resident's plan of care until the comprehensive care plan was developed according to the Resident Assessment Instrument (RAI) process, no later than the resident's first quarterly assessment. Review of Resident #61's medical record revealed the resident was admitted from another facility, on 08/16/2021. The resident's admitting diagnoses included Dementia, Hypertension, Diabetes Mellitus without Complications, Depression, and Mild Protein-Calorie Malnutrition. Review of the admission Minimum Data Set (MDS) Assessment, dated 08/27/2021, revealed the Brief Interview for Mental Status (BIMS) score for Resident #61 was three (3) of fifteen (15), indicating severe cognitive impairment. However, the resident was also assessed as being alert and oriented to person and place. Observation, on 10/05/2021 at 11:11 AM, revealed Resident #61 was in his/her private room, sitting on the couch, with puzzle books on the table untouched. Resident #61 pointed out a drawing of his/her house, detailed its location, and how he/she would like to go home. Resident #61 stated the bedspread was crooked but nobody cares that it was not set the way it should have been. The resident reported he/she was bored. Additional observation, on 10/05/2021 at 2:44 PM, revealed Resident #61 heading toward the door leading to the central/lobby area. He/she asked if the daughter was waiting outside the door. Additional observation, on 10/05/2021 at 4:40 PM, revealed Resident #61 again wandering in the unit hallway. The resident used a rollater for ambulation and stated he/she was looking for something to do. Review of Resident #61's Basic Care Plan, on the electronic medical record (EMR), revealed the element for staff dependence for activity, cognitive dependence, and social interaction had no interventions. Further review revealed that the only entries on the care plan were dated 08/16/2021. The review showed a care plan review date of 09/05/2021, but no reviews or updates were documented. Additional care plan review revealed it was not completed or updated on the EMR, with no review or updates recorded. The care plan was also redlined (alerted) with overdue indicators. Interview with the MDS Coordinator, on 10/07/2021 at 3:45 PM, revealed the Licensed Practical Nurse ( LPN) in the MDS office, printed off orders every day and then added those new interventions to the residents' individual care plans. She stated nurses had access to add goals and interventions but many did not because, with anything significant, they would have called the physician. Therefore, she stated, whatever orders came from the physician, generated the changes to the care plan during the daily updates. She also stated that a basic care plan was initiated as soon as the admission dataset was completed; and, the next day the MDS office staff was at work, trying to complete the comprehensive care plan. She further reported the care plan could be saved even while incomplete. She stated, when reviewing the care plan, if the button for Complete Review was not clicked, it would not show as completed. She stated she could not think of a situation that would lead to failure in the system to capture/complete a new care plan. She stated she believed there was a fourteen (14) day deadline for completion of the first comprehensive care plan. Interview with LPN #4 and Registered Nurse (RN) #1, on 10/07/2021 at 4:10 PM, revealed nurses scanned care plans for changes at the beginning of the shift, as well as getting verbal shift report. In addition, they stated the Acute Monitoring Log was always viewed at the beginning of the shift, then changes were added throughout the shift. LPN #4 also stated that updates to Activities interventions, for example, were communicated verbally, but the nurses would look to an individual care plan for specifics. Subsequent review of Resident #61's care plan revealed an activity care plan element had interventions added, on 10/07/2021, after being begun on 08/16/2021. Further, review of the various elements continued to show overdue status for care plan review. Interview with the Administrator, on 10/07/2021 at 5:22 PM, revealed her expectation that staff would look to the care plan to guide the care provided, and staff should all be looking at care plans every day. She further revealed staff used the projector at their team meetings and reviewed the care plans together. She also stated when staff members were discussing a resident, they were reviewing interventions that were in place and whether any goals or interventions should be added or removed. The Administrator additionally reported that every resident's care plan was reviewed regularly in this manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of twenty-four (24) sampled residents (Sampled Resident #26). Review of the comprehensive care plan (CCP) revealed Resident #26 required transfer by a mechanical device. However, nursing staff did a transfer, with Resident #26, without using a mechanical lift, which resulted in a fall. The findings include: Review of the facility's policy titled, Base Line Care Plan, not dated, revealed the facility must develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person centered care and met professional standards of quality of care for each resident. Review of the facility's Incident Report, dated 09/26/2021 at 5:25 PM, revealed the nurse walked into Resident #26's room to find the resident on the floor beside the bed. Nurse Aide #2 and State Registered Nurse Aide (SRNA) #4 were already in the room. Per the report, when the nurse asked what happened they stated we didn't know the resident was a Hoyer lift (brand of mechanical lift), and we tried to get him/her out of bed. The report stated the aides were re-educated on where to find information related to a resident's transfer status. In addition, the report stated Resident #26 denied pain/discomfort; no injuries were noted; and the physician and family were notified. Review of Resident #26's medical record revealed the facility admitted the resident, on 10/23/2020, with diagnoses including Major Depression, Anxiety, Diabetes Type 2, and Hypertension. The Quarterly Minimum Data Set (MDS) Assessment, dated 07/27/2021, for Brief Interview for Mental Status (BIMS) showed the resident scored twelve (12) of fifteen (15), for cognitively intact. Continued review revealed, under section J, one (1) fall with no injuries. Also, review of the admission MDS Assessment, dated 10/30/2020, revealed, under section V, a concern care area identified for falls. Review of Resident #26's Aide [NAME], date of admission [DATE], revealed, under Transferring, mechanical lift only, with green light pad. Further review revealed, under Mobility, non-ambulatory. Review of Resident #26's Comprehensive Care Plan (CCP), dated 10/23/2020, under Focus, Falls, revealed a potential risk for falls due to confusion and at high risk for falls. Under goals, the CCP listed for the resident to be free from injury through the review date of 08/23/2021. Further review revealed interventions were 1) added falling star program, date initiated 03/03/2020 and created 04/12/2021; 2) educated resident to allow staff to use mechanical lift for transfers, date initiated, created, and revised 08/23/2021; and 3) transfers with mechanical lift with [NAME] lift pad, date initiated, created, and revised 06/09/2021. Further review of Resident #26's CCP, dated 10/26/2020, under Focus, Activities of Daily Living (ADL) related to Self Care Performance Deficit, revealed the intervention of transfer with mechanical lift only [NAME] lift pad, date initiated 06/08/2021. Further review of Resident #26's CCP, dated 10/26/2020, under Focus, Limited Physical Mobility, revealed a goal of the resident would maintain his/her current level of mobility through the review date. The CCP stated, under interventions, the resident was non-ambulatory, with the date initiated and created of 10/26/2020, and the revision date of 08/11/2021. Interview with Nurse Aide #2, on 10/07/2021 at 1:54 PM, revealed she was assisting, with SRNA #4, in transferring Resident #26 from the bed to the chair when the resident was lowered to the floor. She stated the resident made the request to move to the chair. She stated Resident #26 had no injuries. In addition, Nurse Aide #2 stated the [NAME] was available on the Kiosk on the floor, and she was not aware Resident #26 used a mechanical lift for transfers. Nurse Aide #2 further revealed she did not have access to the Kiosk the day of the fall. Interview with SRNA #4, on 10/07/2021 at 2:28 PM, revealed she tried to transfer Resident #26 because Nurse Aide #2 told her Resident #26 wanted to get in the chair. SRNA #4 stated she did not know if Resident #26 still used a lift. She stated she checked the [NAME], and it stated Resident #26 was transferred using a mechanical lift. She stated the resident refused to use the mechanical lift. SRNA #4 stated they used a gait belt and realized they could not transfer with only the gait belt. SRNA #4 stated, with the assist of Nurse Aide #2, they lowered Resident #26 to the floor. SRNA #4 further revealed she should have notified the nurse the resident refused to use the mechanical lift. SRNA #4 stated she should have followed the care plan and used the mechanical lift to transfer Resident #26. Interview with the Director of Nursing (DON), on 10/07/2021 at 2:28 PM, revealed an incident report was filled out by the nurse. She stated staff had access to the [NAME], located on the Kiosk, for information on resident care. She stated both Nurse Aide #2 and SRNA #4 reviewed the [NAME] which stated the resident was transferred by using a mechanical lift. The DON stated Resident #26 was refusing transfer by a mechanical lift. She stated SRNA #4 should have notified the nurse and not transferred the resident. The DON stated the transfer information was on the [NAME] and the aides did not follow the care plan. In addition, the DON stated training was provided to nursing staff during orientation concerning use of the [NAME]. Interview with the Administrator, on 10/07/2021 at 3:06 PM, revealed SRNA #4 reviewed the [NAME] for Resident #26 and had prior knowledge the resident was a mechanical lift. The Administrator stated Nurse Aide #2 and SRNA #4 should have told the nurse before the transfer, if resident refused the mechanical lift. In addition, the Administrator stated Nurse Aide #2 and SRNA #4 did not follow the care plan and immediately received education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision and provide a mechanical device to prevent falls for one (1) of twenty-four (24) sampled residents (Resident #26). Resident #26 was assisted with transfer without use of a mechanical lift, which resulted in a fall. The findings include: Review of the facility's policy titled, Falls Program, undated, revealed this program identified residents at risk of falls, and if at risk, the resident would be placed in the Falling Stars program. Per the policy, after each fall, the environment would be assessed for causative factors. The policy stated, for the Falling Stars program, a symbol was placed beside the resident's name on the room number sign and on a list at the nurse's station. Review of the facility's protocol titled, Falls Follow-Up Protocol, undated, revealed an incident report would be completed at the time of the fall incident, with an attempt made to determine causative factors. In addition, a licensed nurse would assess the resident at the time of the incident. Per the policy, once the incident report was completed, it was given to the Director of Nursing (DON) and the Administrator. Review of the facility's Incident Report, dated 09/26/2021 at 5:25 PM, revealed the nurse walked into Resident #26's room to find the resident on the floor beside the bed. Nurse Aide #2 and State Registered Nurse Aide (SRNA) #4 were already in the room. Per the report, when the nurse asked what happened they stated we didn't know the resident was a Hoyer lift (brand of mechanical lift), and we tried to get him/her out of bed. In addition, the report stated Resident #26 denied pain/discomfort; no injuries were noted on the nursing assessment; and the physician and family were notified. Review of Resident #26's medical record revealed the facility admitted the resident, on 10/23/2020, with diagnoses including Major Depression, Anxiety, Diabetes Type 2, and Hypertension. The Quarterly Minimum Data Set (MDS) Assessment, dated 07/27/2021, for Brief Interview for Mental Status (BIMS) showed the resident scored twelve (12) of fifteen (15), for cognitively intact. Continued review revealed, under section J, one (1) fall with no injuries. Also, review of the admission MDS Assessment, dated 10/30/2020, revealed, under section V, a concern care area identified for falls. Review of Resident #26's Medication Review Report, dated 10/2021, revealed the resident was a high risk for falls, active 10/23/2020, and was active, as of 08/23/2021, in the Falling star program (a program used to prevent falls). Review of Resident #26's Comprehensive Care Plan (CCP), revealed, under interventions, 1) the resident was non-ambulatory, with the date initiated and created of 10/26/2020, and the revision date of 08/11/2021; 2) the resident was educated to allow staff to use the mechanical lift for transfers, date initiated, created, and revised 08/23/2021; and 3) transfers to be done with the mechanical lift with [NAME] lift pad, date initiated, created, and revised 06/09/2021. Review of Resident #26's Aide [NAME], date of admission [DATE], revealed, under Transferring, mechanical lift only, with [NAME] lift pad. Further review revealed, under Mobility, non-ambulatory. Interview with Resident #26, on 10/07/2021 at 1:45 PM, revealed he/she was the one that asked to be transferred, and it was his/her fault concerning the fall. The resident stated the aides had nothing to do with the fall because he/she had asked them not to use the mechanical lift. Interview with Nurse Aide #2, on 10/07/2021 at 1:54 PM, revealed she was assisting, with SRNA #4, in transferring Resident #26 from the bed to the chair using only a gait belt, when the resident was lowered to the floor. She stated the resident made the request to move to the chair and did not want to use the mechanical lift. She stated Resident #26 had no injuries. Nurse Aide #2 stated, before the resident was transferred, she should have notified the nurse that the resident refused to use the mechanical lift. Interview with SRNA #4, on 10/07/2021 at 2:28 PM, revealed she and Nurse Aide #2 tried to transfer Resident #26 from the bed to the chair. She stated she checked the [NAME], and it stated Resident #26 was transferred using a mechanical lift. She stated the resident refused to use the mechanical lift. SRNA #4 stated both she and Nurse Aide #2 used a gait belt for the transfer. She stated, at that time, they realized they could not transfer the resident with only the gait belt. SRNA #4 stated, with the assist of Nurse Aide #2, they lowered Resident #26 to the floor. Per the interview, SRNA #4 stated she should have notified the nurse that the resident refused to use the mechanical lift before Resident #26 was transferred. Interview with the Director of Nursing (DON), on 10/07/2021 at 2:28 PM, revealed an incident report was filled out by the nurse for the fall incident with Resident #26, on 09/26/2021. She stated both Nurse Aide #2 and SRNA #4 reviewed the [NAME] which stated the resident was transferred only by using a mechanical lift. The DON stated, even though Resident #26 was refusing transfer by the mechanical lift, the aides should have notified the nurse and not transferred the resident using a gait belt. In addition, the DON stated training was provided to nursing staff during orientation concerning transferring a resident, using a mechanical lift. Interview with the Administrator, on 10/07/2021 at 3:06 PM, revealed SRNA #4 knew Resident #26 was a mechanical lift for transfers. The Administrator stated Nurse Aide #2 and SRNA #4 should have told the nurse before the transfer, if the resident refused the mechanical lift.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to limit as needed (PRN) orders for antipsychotic drugs to fourteen (14) days without the attending physician or prescribing practitioner evaluating the resident for the appropriateness of that medication for one (1) of twenty-four (24) sampled residents (Resident #15). The findings include: Review of the facility's policy titled, Medication Ordering and Prescribing Psychoactive Medication Use-General, not dated, revealed residents did not receive PRN (as needed) psychotropic medications unless necessary to treat a diagnosed specific condition which must be documented in the record. The policy stated PRN orders for psychotropic medications, which were antipsychotic medications, were limited to fourteen (14) days. Then, the PRN order for an antipsychotic could not be renewed until the physician or prescriber evaluated the resident to determine if the medication was appropriate. Per the policy, the evaluation should include direct evaluation and assessment of the resident's condition and progress to determine if the PRN antipsychotic medication was still needed. Review of Resident #15's medical record revealed the facility admitted the resident, with hospice care, on 12/16/2020, with diagnoses of Anxiety, Alzheimer's Dementia, Depression, and Macular Degeneration. Further review revealed hospice care was discontinued on 04/01/2021, with a Significant Change MDS Assessment completed, on 04/10/2021, which indicated, in section E for Behaviors, there were no behaviors exhibited from the resident for the month prior to 04/10/2021. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/08/2021, revealed the facility assessed the Resident with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), for severe cognitive impairment. Also, it revealed, in section E for Behaviors, no behaviors exhibited from the resident for the month prior to 07/08/2021. Review of the Quarterly MDS Assessment, dated 03/18/2021, section E for Behaviors, revealed no behaviors exhibited from the resident for the month prior to 03/18/2021. Review of Resident #15's Comprehensive Care Plan, dated 12/16/2020, revealed there was a focus of impaired thought process, related to severely impaired cognition, decision making with diagnosis of Dementia, Mood Disorder, and Depression. The goal was for the resident was to develop skills to cope with cognitive decline and maintain safety by the next review date. An intervention, dated and initiated on 12/16/2020, revealed to give Ativan as ordered PRN for anxiety. Review of Resident #15's Order Summary Report, dated 10/2021, revealed an order for Ativan (Lorazepam, an anti-anxiety agent) tablet 0.5 mg, one (1) tablet by mouth every twelve (12) hours as needed (PRN) for anxiety and comfort care. The order date and start date was 12/16/2020, with no indication of a fourteen (14) day stop date. Review of Resident #15's history and physical, dated 12/29/2020, revealed the resident was on Ativan 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN, and it had been taken by the resident. Review of the resident's history and physical, dated 07/01/2021, revealed the resident was on Ativan 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN, and it had been taken by the resident, starting 01/20/2021. Review of Resident #15's history and physical, dated 07/25/2021, from a psychiatric consultant, revealed, under Gradual Dose Reduction (GDR), that it was not recommended to discontinue medications, otherwise psychiatric symptoms would worsen. However, there was no reference to the resident receiving Ativan 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN. Review of the Medication Administration Record (MAR) dated for the months of 12/2020, 05/2021, 07/2021, 08/2021, and 10/2021 revealed Ativan 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN for anxiety and comfort care was not given. Continued review, for 10/01/2021 through 10/06/2021, revealed Ativan was not given. Additional review of the MAR revealed the medication Ativan 0.5 mg, give one (1) tablet by mouth every twelve (12) hours PRN for anxiety and comfort care was given once on 01/10/2021, 01/16/2021, 02/08/2021, 02/09/2021, 02/11/2021, 02/12/2021, 02/15/2021, 02/16/2021, 02/17/2021, 03/06/2021, 03/07/2021, 03/11/2021, 03/12/2021, 03/16/2021, 03/17/2021, 03/21/2021, 04/08/2021, 06/14/2021, 06/24/2021, 09/21/2021 and 09/22/2021. It was given twice on 04/13/2021. The Ativan tablets given were listed on the MAR as effective. Review of Communication with Practitioner Situation sheet, dated 10/07/2021, revealed Resident #15 was given Ativan very few times in the last six (6) months. The physician discontinued Ativan related to non-use. Review of the Pharmacy form Note to Attending Physician/Prescriber, dated 12/23/2020, revealed a recommendation by Pharmacist Consultant #2 to extend Ativan 0.5 by mouth for PRN anxiety and comfort care for six (6) months and to re-assess the need at that time for Resident #15. The Physician/Prescriber Response was not given or signed. Review of the Pharmacy form Note to Attending Physician/Prescriber, dated 09/29/2021, revealed a recommendation, by Pharmacist Consultant #2, to extend Ativan 0.5 by mouth for PRN anxiety and comfort care for six (6) months and to re-assess the need at that time for Resident #15. The physician declined the recommendation and did not wish to implement the change due to risk vs. benefit considered; however, no stop date or rationale was given to continue the current prescription. Interview with Resident #15's Physician was not successful. The physician was not available, on 10/07/2021 at 12:02 PM, and a voice message was left by the State Survey Agency (SSA) Surveyor, concerning Resident #15. A call, from the physician, was not returned as of 10/07/2021 at 6:15 PM, upon exit from the facility. Interview with Clinical Pharmacy Director #1, on 10/07/2021 at 11:35 AM, revealed the Pharmacist Consultant for the facility would make a recommendation(s) and would await a response from the physician. She stated pharmacists tried to clarify and follow-up with physicians concerning the pharmacy recommendations. Interview with Pharmacist Consultant #2, on 10/07/2021 at 12:15 PM, revealed the policy was for PRN Ativan to have a fourteen day (14) stop date. He revealed he did not have a regimented time frame to review for PRN medications. He stated he had recommended, on 12/23/2020, an extended stop date of six (6) months because Resident # 15 was in hospice care. He stated he believed the resident was on hospice care until 03/29/2021. He stated he was informed the recommendation for Resident #15, made on 12/23/2020, had not been seen by the physician. He stated the recommendation for use of PRN antipsychotics was limited to fourteen (14) days with a rationale for a new order extending another fourteen (14) days or rationale for an extended period of time. He further revealed the resident had not used Ativan PRN for 07/2021 and 08/2021. Also, he stated the resident had not used Ativan PRN for 10/01/2021 through 10/06/2021, and he would recommend to discontinue the Ativan. Interview with Licensed Practical Nurse (LPN) #1, 200 North Unit, on 10/07/2021 at 1:50 PM, revealed she was aware of Resident #15's Ativan PRN medication. She stated the pharmacy made the recommendations and notified the physician if the resident was not taking PRN medications. She also stated the physician was not always timely in acting on pharmacy recommendations. Interview with Director of Nursing (DON), on 10/07/2021 at 2:45 PM, revealed the facility's policy was for a fourteen (14) day stop for PRN psychiatric medications and then to reassess the need. She stated the facility communicated with the pharmacy and checked daily for any recommendations. Then, she stated the recommendations were shared with the Nurse Managers through their Dash board system. She stated any recommendations from pharmacy were sent with three (3) copies. One (1) copy was given to the Nurse Manager, one (1) copy stayed in the binder in the Assistant Director of Nursing's (ADON) office, and the other was sent to the DON. She stated a copy was sent to the physician. Then, after the physician reviewed and sent back his response to the pharmacy recommendation, the completed copy was flagged and placed into the binder. The DON stated once the response to the pharmacy recommendation was completed, it was sent back to pharmacy. The DON revealed, through review of the resident's MAR, pharmacy made recommendations to the physician to discontinue a medication if it had not been taken. Interview with the Administrator, on 10/07/2021 at 2:54 PM, revealed the facility's policy was for anti-psychotics to be limited to fourteen days (14) days. She stated the physician placed the order and used medical judgment on why to continue the medication. She stated Psychiatric Services could document and recommend not to reduce the PRN psychiatric medication. The Administrator stated all PRN medications were reviewed in the morning clinical meeting.