**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living received the necessary services to maintain good grooming and personal hygiene for 1 (#35) of 3 (#3, #23, #35) residents reviewed for Activities of Daily Living (ADL) care. Findings: Resident #35 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction with hemiparesis affecting right dominant side. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed in section C- Cognitive Patterns that resident #35 had a brief interview of mental status (BIMS) score of 6 which indicated severe cognitive impairment. Further review of the MDS revealed in section GG-Functional Abilities that resident #35 was dependent on staff for personal hygiene care that included nail care. Review of March 2025 physician orders revealed an order dated 03/12/2025 for fingernail care every shift for resident #35. Review of the Electronic Medication Administration Record for March 2025 revealed fingernail care was documented every shift for resident #35.from 03/12/2025 - 03/24/25. Observation of resident #35 on 03/24/2025 at 11:13 a.m. revealed his right hand was contracted with long fingernails. On 03/25/2025 at 12:44 p.m., an observation of resident #35`s right hand was conducted in his room, and S5Licensed Practical Nurse (LPN) confirmed resident #35`s fingernails to his right hand were long and in need of trimming. On 03/25/2025 at 01:21 p.m., an interview with S2Director of Nurses (DON) confirmed there should not have been documentation of nail care being provided every shift if it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure residents with a history of falls, received appropriate interventions to prevent future falls for 1 (#22) of 4 (#22, #30, #41, #63) residents reviewed for falls. Findings: Record review revealed resident #22 was admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities, generalized anxiety disorder, epilepsy, right femur fracture, and autistic disorder. Review of accident/incident reports revealed resident #22 had a fall from his bed witnessed by S3Certified Nursing Assistant (CNA) Supervisor as she was assisting him to get dressed on 02/07/2025. Review of the S3CNA Supervisor`s hand written witness statement included in the complaint investigation revealed resident #22 was on the floor tangled up in his bedding. On 03/26/2025 at 2:31 p.m., an interview with S3CNA Supervisor confirmed she was assisting resident #22 getting dressed on 02/07/2025. S3CNA Supervisor reported resident #22 was fully dressed laying on top of the bed covers. S3CNA Supervisor turned away from resident #22 to get his shoes, which were on the floor beside the bed. S3CNA Supervisor reported as she had her back turned away from resident #22 she heard a noise, and discovered resident #22 was on the floor on the opposite side of the bed. S3CNA Supervisor did not mention the resident being tangled up in his bedding on the floor. Review of resident #22's fall investigation report dated 02/07/2025 revealed the fall committee determined the new intervention would be to have CNA to place resident's pants on while in bed . Review of the active care plan related to falls revealed an intervention for staff to get resident #22 dressed and put pants on while in bed after the fall on 02/07/2025. On 03/26/2025 at 5:45 p.m., S1Administrator and S2Director of Nurses were informed the interventions were not appropriate related to resident #22`s fall on 02/07/2025.

Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director, and director of nursing for 1 (#8) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications Findings: Review of the record for resident # 8 revealed an admit date of 05/31/2024 with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Review of the Medication Record Review (MRR) for February 2025 revealed no documented evidence that the pharmacist identified duplicate short-acting insulin therapy for resident #8. Record review revealed a physician's order dated 09/23/2024 for Humulin R (short-acting insulin) injected subcutaneously twice daily per sliding scale. Further review revealed an order dated 10/18/2024 for Novolin R (short-acting insulin) injected subcutaneously before meals and at bedtime per sliding scale. Review of the March 2025 Medication Administration Record (MAR) revealed the order for Humulin R (short-acting insulin) dated 09/23/2024 was documented 49 times from 03/01/2025 to 03/25/2025. Review of the March 2025 MAR revealed the order for Humulin R (short-acting insulin) dated 10/18/2024 was documented 99 times from 03/01/2025 to 03/25/2025. An interview conducted with S2Director of Nursing (DON) on 03/26/2025 at 1:30 p.m. confirmed the pharmacist failed to identify and report the irregularity for the duplication of administration of 2 short acting insulins for resident #8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident was free from unnecessary medications by failing to implement a gradual dose reduction for a psychotropic medication for 1 (#14) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. These drugs include, but are not limited to, drugs in the categories of antipsychotics, antidepressants, anti-anxiety, and hypnotics. Findings: Record review revealed resident #14 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, delirium due to known physiological condition, essential hypertension, lower back pain, neuralgia, and neuritis. Review of the March 2025 physician orders revealed the following orders dated 08/05/2024: Quetiapine Fumarate (Seroquel, an antipsychotic medication) 50 milligrams (mg) tablet give one tablet orally one time a day, Bupropion Hydrochloride (HCL) extended release (Wellbutrin, an antidepressant medication) 150 mg tablet give one tablet orally two times a day, Xanax (an anti-anxiety medication) 0.5 mg tablet give one tablet three times a day. Review of the March 2025 Electronic Medication Administration Record (EMAR) revealed documentation resident #14 received Seroquel 50 mg tablet orally every day, Wellbutrin 150 mg tablet orally twice daily, and Xanax 0.5 mg tablet orally three times daily. Review of the Consultant Pharmacist report dated 03/14/2025 revealed there was a recommendation to decrease Seroquel to 25 mg orally (po) qd (every day). S7Family Nurse Practitioner (FNP) had checked the box I agree, please write the order(s) on 03/20/2025. S7FNP did not want to reduce Wellbutrin or Xanax. Further review of the letter revealed documentation S6Licensed Practical Nurse (LPN) had noted and initialed the letter on 03/22/2025. On 03/26/2025 at 10:17 a.m., an interview with S7FNP revealed she reviewed the Consultant Pharmacist gradual dose reduction letter and agreed with the pharmacist's recommendation to decrease Seroquel to 25 mg qd on 03/20/2025. S7FNP further revealed she did not want to decrease the Wellbutrin dosage or Xanax dosage. On 03/26/2025 at 11:15 a.m., an interview with S6LPN revealed she reviewed resident #14's consultant pharmacist psychotropic gradual dose reduction letter on 03/22/2025, but did not notice the order to decrease Seroquel to 25 mg po qd. During an interview on 03/26/2025 at 11:20 a.m. with S2Director of Nursing (DON) revealed she had not reviewed the consultant pharmacist psychotropic gradual dose reduction letter dated 03/14/2025. Surveyor and S2DON reviewed the consultant pharmacist psychotropic gradual dose reduction letter together, and S2DON confirmed S7FNP had agreed with the pharmacist recommendation to decrease Seroquel to 25 mg po qd on 03/20/2025. S2DON confirmed resident #14's Seroquel should have been decreased to 25 mg po qd.

Resident #13 Observations on 03/24/2025 at 9:09 a.m. and 03/25/2025 at 9:25 a.m. of resident #13's room revealed her air conditioner (AC) ventilation (vent) cover was dirty with a buildup of dirt and grime. Also, the AC vent area had a large amount of trash and debris noted on the bottom portion of the vent. Further observation revealed the left side of resident #13's bed footboard was not attached or secured to the bed frame which caused the left side of the footboard to be positioned lower than right side. Also, resident #13's small dresser's middle drawer was missing the facing. On 03/26/2025 at 10:35 a.m., the surveyors and S1Administrator observed all the above environmental concerns and he confirmed resident #13's AC vent cover and ventilation area were dirty and were in need of cleaning. S1Administrator also confirmed resident #13's small dresser and bed footboard were in need of repair. Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 3 (#2, #13, and #27) of 4 (#2, #13, #33, and #27) sampled residents reviewed for environmental issues. The facility failed to ensure: 1. Resident #2, #13, and #27's air conditioning/heating units were free from trash and debris; 2. Resident #2's air conditioning/heating unit had control knobs attached; 3. Resident #2's television frame remained in good repair; and 4. Resident #13's dresser and bed footboard remained in good repair. Findings: Resident #2 On 03/24/2025 at 10:04 a.m. observation of resident #2's room revealed the air conditioning/heating unit contained debris and the unit control knobs were missing. The television frame was also observed separated from the top left corner of the television. On 03/25/2025 at 9:06 a.m. observation of resident #2's room revealed debris remained in air conditioning/heating vent and control knobs remain missing. On 03/26/2025 at 10:35 a.m. the surveyors and S1Administrator observed the air conditioning/heating unit and he confirmed debris in air conditioning/heating unit and control knobs missing from unit. S1Administrator stated he would have control knobs replaced and debris cleaned from air conditioning/heating unit or have unit replaced. On 03/26/2025 at 2:00 p.m. the surveyors and S1Administrator observed broken television frame and he confirmed that frame on top left of television was broken and separated from the television. S1Administrator stated he would have frame repaired or replace television. Resident #27 On 03/24/2025 at 9:00 a.m., 03/25/2025 at 8:50 a.m., and 03/26/2025 at 8:50 a.m., observations of resident #27's room revealed the air conditioning/heating unit contained debris. On 03/26/2025 at 10:35 a.m. the surveyors and S1Administrator observed all above environmental concerns and he confirmed air conditioning/heating unit vents were dirty and would have them cleaned or replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM or prevent further decrease in ROM for 2 (#3 and #23) of 3 (#3, #23, and #35) residents reviewed for limited range of motion. Findings: Resident #3 Review of the record for resident #3 revealed an admission date of 09/27/2016 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, contracture right wrist, abnormal posture, dysphagia following cerebral infarction, muscle wasting and atrophy of left thigh, right lower leg, right thigh, and aphasia following other cerebrovascular disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. Further review of the MDS revealed resident requires maximal assistance with activities of daily living and functional limitation in range of motion on 1 side for upper and lower extremities. Review of the March 2025 Physician's Orders for resident #3 revealed an order dated 08/10/2024 for Certified Nurse Aid (CNA) to perform active/passive ROM to upper and lower extremities daily for 5 minutes due to diagnosis of hemiparesis. Review of the February 2025 and March 2025 Medication Administration Record (MAR) revealed no documentation of ROM daily to upper and lower extremities provided to resident #3. Review of resident #3's current care plan revealed the care plan included hemiparesis/hemiplegia with the following intervention: ROM active or passive with morning/evening care daily. Observations of resident #3 on 03/24/2025 at 9:55 a.m., 03/25/2025 at 1:10 p.m. and 03/26/2025 at 10:05 a.m. revealed resident was up in his wheelchair and had a contracture to his right hand, right wrist, and right elbow. An interview on 03/26/2025 at 10:38 a.m. with S9CNA revealed she provides care to resident #3 and confirmed resident does have a contracture to his right hand, right wrist, and right elbow. S9CNA confirmed she has not documented ROM for resident #3. An interview on 03/26/2025 at 10:45 a.m. with S8Licensed Practical Nurse (LPN) revealed resident #3 has a contracture to his right hand, right wrist, and right elbow. An interview on 03/26/2025 at 11:00 a.m. with S2Director of Nursing (DON) confirmed resident #3 has a contracture to his right hand, right wrist, and right elbow, and confirmed resident #3 should be provided active and passive ROM daily. S2DON further confirmed there was no documentation of ROM provided for resident #3 for February and March 2025. Resident #23 Review of the record for resident #23 revealed an admission date of 05/23/2018 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, monoplegia of lower limb following cerebral infarction affecting right dominant side, vascular dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, vascular dementia unspecified severity with behavioral disturbance, epilepsy unspecified no intractable without status epilepticus. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed resident required moderate to maximal assistance with activities of daily living, and functional limitation in ROM with impairment on 1 side to upper and lower extremities. Review of March 2025 Physician's Orders for resident #23 revealed an order dated 08/13/2024 for a CNA to perform active/passive ROM to upper and lower extremities during daily personal care daily for 5 minutes due to a diagnosis of hemiparesis. Review of the February 2025 and March 2025 MAR revealed no documentation of ROM daily to upper and lower extremities provided to resident #23. Review of resident #23's care plan dated 11/18/2020 revealed the care plan included potential for impaired activities of daily living independence related to hemiplegia and right sided weakness. Further review of the care plan revealed an intervention to provide ROM as tolerated. Observations of resident #23 on 03/24/2025 at 9:00 a.m., 03/25/2025 at 1:05 p.m., and 03/26/2025 at 10:05 a.m. revealed resident had a contracture to his right hand. An interview on 03/26/2025 at 10:38 a.m. with S9CNA revealed she provides care to resident #23 and confirmed resident does have a contracture to his right hand. S9CNA confirmed she has not documented ROM for resident #23. An interview on 03/26/2025 at 10:45 a.m. with S8LPN revealed resident #23 has a contracture to his right hand. An interview on 03/26/2025 at 11:00 a.m. with S2DON confirmed resident #23 has a contracture to his right hand, and confirmed that resident should have active and passive range of motion daily. S2DON further confirmed there was no documentation of ROM provided to resident #23 for February and March 2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident with a urinary catheter received appropriate care and services to prevent urinary tract infections by having the urinary catheter tubing on the floor and not having justification for the use of an indwelling Foley catheter for 1 (#8) of 2 (#8, #63) residents reviewed for urinary catheters. Findings: Review of the record for resident # 8 revealed an admit date of 05/31/2024 with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Record review revealed a physician's order dated 12/12/2024 for resident # 8 to have a Foley catheter changed on the 12th of every month related to frequency of micturition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #8 had a brief interview for mental status (BIMS) score of 4 which indicated severe cognitive impairment. Further review of the MDS data revealed the presence of an indwelling urinary catheter, and required substantial/maximal assistance with toileting hygiene. Review of the record for revealed resident #8 had urinary tract infections on 12/15/2024, 01/16/2025, and 02/02/2025 and was treated with antibiotics. Further review of the record revealed resident returned from the hospital on [DATE] with continued treatment for a UTI. Observations of resident #8 on 03/24/2025 at 10:21 a.m., 03/24/2025 at 11:37 a.m., and 03/25/2025 at 12:29 p.m. revealed resident was up in her wheelchair and her indwelling urinary catheter tubing was noted laying on the floor beneath her wheelchair. An interview and observation was conducted with S2Director of Nursing (DON) on 03/25/2025 at 1:15 p.m. in resident # 8's room. Resident # 8's indwelling urinary catheter tubing was observed on the floor. S2DON confirmed that resident # 8's indwelling urinary catheter tubing should not be laying on the floor. An interview with S2DON on 03/25/2025 at 3:43 p.m. confirmed that resident #8 did not have a justification for the use of an indwelling urinary catheter placement.

Based on record review and interview, the facility failed to ensure that the licensed nurses have the specific competencies and skill sets necessary to care for a resident's needs for 1 (# 8) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications. The licensed nurses were duplicating documentation of administration of 2 different short-acting insulins. Findings: Review of the record for resident # 8 revealed an admit date of 05/31/2024 with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Record review revealed a physician's order dated 09/23/2024 for Humulin R (short-acting insulin) injected subcutaneously twice daily per sliding scale. Further review revealed an order dated 10/18/2024 for Novolin R (short-acting insulin) injected subcutaneously before meals and at bedtime per sliding scale. Review of the March 2025 Medication Administration Record (MAR) revealed the order for Humulin R (short-acting insulin) dated 09/23/2024 was documented 49 times from 03/01/2025 to 03/25/2025. Review of the March 2025 MAR revealed the order for Novolin R (short-acting insulin) dated 10/18/2024 was documented 99 times from 03/01/2025 to 03/25/2025. An interview conducted with S2Director of Nursing (DON) on 03/26/2025 at 1:30 p.m. confirmed the licensed nurses were duplicating documentation of administration of 2 short-acting insulins for resident #8. S2DON verified that resident #8 only received 1 short-acting insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify the resident's representative after an accident for 2 (#1, #2) of 2 (#1, #2) residents reviewed for falls. Findings: Resident #1 Review of the record for resident #1 revealed an admit date of 12/04/2024 with diagnoses in part of alcohol dependence with withdrawal, other seizures, pain, anxiety disorder, shortness of breath, malignant neoplasm of palate, pulmonary embolism without acute cor pulmonale, malignant neoplasm of overlapping sites of oropharynx, cerebral ischemia, dysphagia, and severe protein calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the current plan of care for resident #1 revealed at risk for falls related to impaired balance, and unsteady gait. Review of the Incident and Accident report dated 12/10/2024 at 2:20 a.m. revealed resident #1 was found by S3Licensed Practical Nurse (LPN) sitting on the floor with no injuries noted. Further review of the medical record revealed no documented evidence that S3LPN notified resident #1's responsible party of the fall. On 01/07/2025 at 3:00 p.m., an interview with S2Director of Nurses (DON) confirmed S3LPN should have notified resident #1's responsible party after a fall on 12/10/2024. Resident #2 Review of the record for resident #2 revealed an admit date of 09/04/2024 with diagnoses in part of epilepsy, profound intellectual disabilities, congenital malformation syndromes predominately affecting facial appearance, autistic disorder, dysphagia, scoliosis, microcephaly, and Hallermann-[NAME] Syndrome. Review of the Quarterly MDS assessment dated [DATE] revealed unable to assess resident #2's BIMS score and was dependent on staff for all activities of daily living. Review of the current plan of care for resident #2 revealed at risk for falls, history of falls, multiple risk factors related to impaired balance, poor coordination and unsteady gait. Review of the Incident and Accident report dated 12/10/2024 at 5:30 p.m. completed by S3LPN revealed resident #2 was kicked in the side by another resident resulting in a fall with an injury to his face. Further review of the medical record revealed no documented evidence that S3LPN notified resident #2's responsible party of the fall. On 01/07/2025 at 3:00 p.m., an interview with S2DON confirmed S3LPN should have notified resident #2's responsible party after a fall on 12/10/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident assessment was transmitted in a timely manner by failing to transmit the resident assessment within 7 days of completion for 1 (Resident #5) of 1 (Resident #5) residents reviewed for resident assessments. Findings: Review of resident #5's record revealed resident expired at the facility on [DATE]. Review of the resident #5's Minimum Data Set (MDS) assessments revealed the last assessment was a significant change assessment dated [DATE]. Further review of the MDS revealed there was no discharge assessment completed and transmitted for resident #5. An interview on [DATE] at 2:35 p.m. with S2Assistant Director of Nursing (ADON) confirmed that resident #5 expired at the facility on [DATE]. S3ADON confirmed that a discharge assessment was not completed on resident #5. S3ADON confirmed that a discharge assessment should have been completed on resident #5 on [DATE] and transmitted by [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure that the plan of care had been revised for 1 (#4) of 1 (#4) residents' care plans reviewed for limited range of motion. Findings: Record review revealed resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses include essential hypertension, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, other sequelae of cerebral infarction, abnormal posture, lack of coordination, history of falling, contracture right wrist, contracture of muscle unspecified, aphasia following cerebrovascular disease, dysphagia following cerebral infarction, unspecified abnormalities of gait and mobility, and chronic pain. Review of the yearly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A further review of the MDS revealed resident was documented as having range of motion impairment on one side, in his upper and lower extremities. Review of resident #4's care plans revealed the only care plan related to contractures was a restorative nursing care plan with an onset date 08/21/2019 and ending date of 10/23/2019 that was prepared by S3ADON (Assistant Director of Nursing). Goal: Safely perform transfers, wheel chair to bed and bed to chair. Participate in exercise daily x 15 minutes. Program: Active range of motion to increase strength to extremities- participate in arch exercises for 15 minutes every day. Program: Splint/Brace Assistance - right hand/elbow splint- On in a.m. and Off in p.m. Program: Transfers- sit to stand and stand to sit, and bed to wheelchair cues for safety. Further review of the care plan related to resident #4's contractures of his right wrist and right elbow had not been updated since 10/23/2019 and there was not an active care plan to address his contractures. On 02/27/2024 at 4:00 p.m. an interview with S2DON (Director of Nursing) revealed resident #4's last documented care plan related to contractures of his right hand and elbow was the restorative nursing care plan with a beginning date 08/21/2029 and end date 10/23/2019. S2DON confirm the care plan related to his contractures had not been revised. S2DON further confirmed there was not an active care plan related to resident #4's contractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion by failing to apply a splint daily for 1 (#4) of 1 (#4) residents reviewed for limited range of motion out of 31 sampled residents. Findings: Record Review revealed resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses included essential hypertension, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, other sequelae of cerebral infarction, abnormal posture, lack of coordination, history of falling, contracture right wrist, contracture of muscle unspecified, aphasia following cerebrovascular disease, dysphagia following cerebral infarction, unspecified abnormalities of gait and mobility, and chronic pain. Review of yearly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A further review of the MDS revealed resident was documented as having range of motion impairment on one side in his upper and lower extremities. Review of resident # 4's active February 2024 physician orders revealed an order for Certified Nurse Aide (CNA) to perform active/passive range of motion upper and lower extremities daily x 5 minutes due to hemiparesis which was ordered on 10/27/2022. Further review of the physician orders revealed there was no order for resident to wear splints. Review of the January and February 2024 nurse's notes revealed no documentation of resident #4 refusing to wear his right wrist/hand splint. On 02/26/2024 at 11:00 a.m. an observation of resident #4 revealed he was sitting in a wheel chair in his room, watching television. Resident #4 was noted to have a contracture of his right hand, right wrist, and right elbow. Further observation revealed there were no anti-contracture devices in place. On 02/27/2024 at 10:15 a.m. an observation of resident #4 revealed he was sitting in a wheel chair in his room, watching television. Resident #4 was noted to have a contracture of his right hand, right wrist, and right elbow with no anti-contracture device in place. Observation of resident #4's room revealed a blue wrist/hand splint and elbow splint sitting on the shelf of his television stand. Resident #4 reported they have not put the splints on in a long time. On 02/27/24 at 9:30 a.m. an interview with S5Rehabilitation Director, COTA (Certified Occupational Therapy Assistant) reported resident #4 last received part B services, Physical Therapy (PT) and Occupational Therapy (OT), on 12/06/2023 through 01/26/2024 due to a fall. S5Rehabilitation Director, COTA reported they put resident #4's right wrist/hand splint on 4 to 6 hours daily while he was receiving therapy. S5Rehabilitation Director, COTA reported resident #4 has not worn his right elbow splint in several years because it no longer fit properly. S5Rehabilitation Director, COTA reported the CNA or nurse should have continued applying resident #4's right wrist/hand splint 4 to 6 hours daily after he was discharged from part B services on 01/26/2024. S5Rehabilitation Director, COTA further reported the CNA should also assist resident #4 with range of motion to upper and lower extremities daily. On 02/27/2024 at 10:35 a.m. an interview with S6LPN (Licensed Practical Nurse) revealed resident #4 has not worn his splints in a long time. On 02/27/2024 at 1:20 p.m. an interview with S7CNA reveled she provided resident #4 with active and passive range of motion to his upper and lower extremities daily. S 7CNA reported resident #4 has not worn his splint on his right wrist/hand in a long time. On 02/27/2024 at 4:00 p.m. an interview with S2DON (Director of Nursing) confirmed resident #4 should wear his right wrist/hand splint 4 to 6 hours daily to help with his contracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice by failing to assess the dialysis access site every shift, according to the facility's policy for hemodialysis access care, for 1 (#53) of 1 (#53) residents reviewed for dialysis. Findings: Review of the facility's policy and procedure on Hemodialysis Access Care revealed the following, in part: 3. Post-care of access site: b.) Nurse will inspect access port for bleeding, redness, or inflammation documenting any changes in the medical chart. Nurse is to notify medical doctor (MD) of any pertinent findings; c.) Nurse is to assess access site to ensure intactness and patency every shift (listening for bruit and feeling for a thrill); d.) Nurse is to document all findings such as condition of dressing (interventions if needed); report from dialysis facility, and observations post-dialysis. Review of the record for resident #53 revealed an admission date of 12/08/2022 with diagnoses including chronic kidney disease stage 5, unspecified atrial fibrillation, heart failure, polycystic kidney, and hypertension. Review of the record for resident #53 revealed the resident has dialysis 2 times per week on Mondays and Fridays. Review of the January 2024 and February 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of monitoring the resident's dialysis access site. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating cognitively intact. Further review of the MDS indicated resident #53 was on dialysis. Review of resident #53's dialysis care plan dated 12/08/2022 included interventions, in part, for staff to assess the access site after returning from dialysis for bleeding and signs and symptoms of infection. Review of January 2024 and February 2024 nurse's notes revealed no documentation of dialysis access site monitoring upon return from dialysis. An interview/observation on 02/27/2024 at 4:00 p.m. with resident #53 revealed that she goes to dialysis on Mondays and Fridays, and occasionally on Wednesdays, if needed. Resident #53 reported she has an access site to the right chest wall. Resident #53 reported that staff from the facility do not check her dialysis access site every shift and upon return from dialysis. Observation revealed a Tessio (central line catheter) to resident's right chest wall with 2 ports, with a Band-Aid over the insertion site. An interview on 02/28/2024 at 9:00 a.m. with S4Licensed Practical Nurse (LPN) revealed resident #53 goes to dialysis on Mondays and Fridays. S4LPN reported she monitors thrill and bruit for resident #53's dialysis access site every shift including when she returns from dialysis. An interview on 02/28/2024 at 9:00 a.m. with S2Director of Nursing (DON) confirmed that resident #53 has a Tessio central catheter to right chest wall for dialysis access. S2DON confirmed dialysis access site should be monitored every shift. S2DON confirmed there was no documentation of monitoring resident #53's dialysis access site every shift including post dialysis in her medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#60) of 6 (#15, #24, #34, #55, #60, and #122) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for pain every shift for resident #60 while receiving pain medication. Findings: Review of the facility's current policy and procedure on Pain-Clinical Protocol revealed, in part: 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review of the facility's current policy and procedure on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and other irregularities, for example: d. inadequate monitoring for adverse consequences; 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services, standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. Resident #60 Review of resident #60's record revealed an admission date of 08/17/2023 with diagnoses including Alzheimer's disease, major depressive disorder, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, anemia, psychotic disorder with hallucinations, anxiety disorder, and mood disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status of 3 indicating severe cognitive impairment. Review of the February 2024 Physician's Orders revealed an order dated 11/14/2023 for Norco 5/325 milligrams tablet 1 by mouth as needed every 8 hours. Review of the January 2024 and February 2024 Medication Administration Record (MAR) revealed no documentation of monitoring for pain every shift. Review of the monthly Medication Regimen Review (MRR) from August 2023 through January 2024 revealed the pharmacist did not identify that resident #60 did not have documentation for monitoring pain every shift while resident was taking pain medication. An interview on 02/28/2024 at 8:55 with S4Licensed Practical Nurse (LPN) revealed resident #60 does complain of pain at times and has administered Norco as needed. S4LPN reported she has not documented monitoring for pain every shift. Interview on 02/28/2024 at 10:25 a.m. with S2Director of Nursing (DON) confirmed that resident #60 did not have documentation of monitoring for pain every shift while taking pain medication. S2DON further confirmed that pharmacist did not identify that the facility was not monitoring for pain for resident #60.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #60 Review of resident #60's record revealed an admission date of 08/17/2023 with diagnoses including Alzheimer's disease, major depressive disorder, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, anemia, psychotic disorder with hallucinations, anxiety disorder, and mood disorder. Review of the February 2024 Physicians Orders for resident #60 revealed the following orders: 11/14/2023- Norco 5/325 mg tab 1 by mouth (po) as needed (prn) every (q) 8 hours (hrs); 08/18/2023- Hydrochlorothiazide (diuretic) 25 mg tablet 1 po daily; and 08/18/2023- Januvia 50 mg tablet 1 po daily. Review of the January 2024 and February 2024 Medication Administration Record (MAR) for resident #60 revealed the following: -No monitoring for edema while taking Hydrochlorothiazide(diuretic); -No monitoring for pain every shift; and -No FSBS prn signs of abnormal glucose. Review of the Consultant Pharmacist Communication to Physician dated 10/20/2023 the pharmacist recommended that while resident #60 was on Januvia (antidiabetic medication)the following was to be done: Fingerstick Blood Sugars (FSBS) accucheck as needed (prn), signs of abnormal glucose and notify doctor if <50 and provide dietary intervention, if >400 notify physician. Physician agreed and signed on 10/30/2023. Review of the Consultant Pharmacist Communication to Nursing dated 10/20/2023 for resident #60 revealed recommendation for edema to be monitored and documented on MAR while resident was on Hydroclorodiazide (diuretic), and was signed and dated by S2DON on 10/23/2023. An interview on 02/28/2024 at 8:55 a.m. with S4LPN revealed she provides care to resident #60. S4LPN revealed she has not documented monitoring for edema or pain every shift, and has not performed FSBS (accuchecks) as needed on resident #60. An interview on 02/28/2024 at 10:25 a.m. with S2DON confirmed the following regarding #60's medication regimen: -no monitoring for edema every shift while taking a diuretic; -facility did not follow the pharmacist recommendation to monitor edema while taking diuretic; -no monitoring for pain every shift while taking pain medication; and -no FSBS accuchecks prn as recommended by pharmacist and ordered by the physician. Resident #34 Review of the medical record revealed sample resident #34 was admitted to the facility on [DATE] with diagnosis of hypothyroidism, diabetes mellitus, hypertension, abnormal posture, vascular dementia, history of falls, anxiety disorder, muscle wasting, lack of coordination, Alzheimer's disease, and osteoarthritis. Review of the yearly Minimum Data Set, dated [DATE] revealed the residents' BIMS (Brief Interview for Mental Status) score was 6, which indicates the resident is cognitively impaired and needs assistance with all activities of daily living. Review of the physician's orders revealed the following: Lantus 100 units/ml give 20 units every day at 8:00 p.m Lantus 100 units/ml give 20 units every day at 6:00 a.m Accu checks before meals and at bedtime with a sliding scale for Lispo insulin 0 units-blood sugar results of 0-200 2 units- blood sugar results of 201-250 4 units- blood sugar results of 251-300 6 units- blood sugar results of 301-350 8 units-blood sugar results of 351-400 10 units- blood sugar results over 400 and notify the Doctor. Review of the Medication Administration Record dated January and February 2024 revealed no documentation of the site insulin was given for the Lantus 20 units at 6:00 a.m and 8:00 p.m and for the sliding scale insulin given. Interview on 02/28/2024 at 10:15 a.m with S4Licensed Practical Nurse (LPN) confirmed she was sample resident #34's nurse and had not documented the site where the insulin was given. Interview on 02/28/2024 at 11:45 a.m with S2DON confirmed there was no documentation of the site the Lantus insulin was given on the medication administration record for January and February or in the medical record. Based on record reviews and interviews the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 4 (#15, #34, #60, and #122) of 6 (#15, #24, #34, #55, #60, and #122) residents reviewed for unnecessary medications. The facility failed to: 1) Monitor residents #15 and #122 for bleeding when administered an anticoagulant, 2) Monitor resident #15's blood pressure when administered an antiarrhythmic medication, 3) Document insulin injection sites for resident #34, 4) Check resident #60 for edema when administered a diuretic, failed to monitor resident #60's blood glucose level, and, failed to 5.) Monitor resident #60 for pain while administered pain medication as needed. Findings: Review of the facility's current policy on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and other irregularities, for example: d. inadequate monitoring for adverse consequences; 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services, standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. Review of the facility's current policy and procedure on Pain-Clinical Protocol revealed in part: 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Resident #15 Review of the medical record for resident #15 revealed an admission date of 01/08/2024 with diagnoses including depression, atrial fibrillation, protein calorie malnutrition, and diabetes mellitus. Review of the current care plan revealed resident #15 had the potential for injury and excessive bleeding related to the use of Eliquis (anticoagulant). Further review of the care plan revealed to monitor for signs and symptoms of bleeding every shift. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and required assistance with activities of daily living. Review of the physician's orders dated 01/08/2024 revealed an order for Eliquis 5 milligrams (mg) per tube two times a day (bid), and Amiodarone HCL (antiarrhythmic) 200 mg to be given two times a day. Review of the Medication Regimen Review (MRR) dated 01/26/2024 revealed the pharmacist recommended that the nurses needs to monitor for bleeding when administering Eliquis, and to monitor blood pressures when administering Amiodarone. Review of the January 2024 and February 2024 Medication Administration Record (MAR) revealed no documented evidence that the staff monitored for bleeding when administering Eliquis, and blood pressure readings were not monitored for resident #15 when administering Amiodarone. On 02/28/2024 at 11:30 a.m., an interview with S2Director of Nursing (DON) revealed Resident #15 was not being monitored for bleeding while receiving Eliquis and there was no monitoring of resident #15's blood pressure when administering Amirodarone. Resident #122 Review of the medical record for resident #122 revealed diagnoses of hemiplegia, open angle glaucoma, depression, hypertension, cerebral infarction, anxiety, schizoaffective disorder, and dementia. Review of the current care plan for resident #122 revealed an approach to administer medications as ordered. Review of the admission MDS assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. Review of the physician's orders dated 02/07/2024 revealed an order for Eliquis 2.5 mg two times a day for 4 weeks. Review of the February 2024 MAR revealed no documented evidence that the staff monitored for bleeding when administering Eliquis. On 02/28/2024 at 11:45 a.m., an interview with S2DON revealed resident #122 was not being monitored for bleeding while receiving an anticoagulant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #60 Review of resident #60's record revealed an admission date of 08/17/2023 with diagnoses including Alzheimer's disease, major depressive disorder, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, anemia, psychotic disorder with hallucinations, anxiety disorder, and mood disorder. Review of the February 2024 Physicians Orders revealed an order dated 11/14/2023 for Clonazepam (Klonopin) 0.5 mg 1 tablet by mouth (po) twice daily as needed. Review of the Consultant Pharmacist Communication to Physician dated 01/26/2024 indicated resident #60 has an order for Klonopin 0.5 mg 1 tablet po twice daily (bid) as needed (prn) agitation/crying. The pharmacist included that Center for Medicare and Medicaid Services (CMS) now requires that all prn psychotropic medication orders be limited to 14 days unless the prescriber believes the duration should be extended. If the above prn order is to be continued past 14 days, please document the rationale and include an intended duration. The physician continued Klonopin 0.5 mg bid prn for the next 6 months on 01/31/2024, but the physician did not include a rationale to continue psychotropic medication prn. An interview on 02/28/2024 at 10:25 a.m. with S2DON confirmed the pharmacy consultant letter dated 01/26/2024 requested physician address resident #60's prn order for Klonopin 0.5 mg bid prn agitation/crying due to a prn psychotropic medication be limited to 14 days. S2DON confirmed the physician did continue prn psychotropic medication for 6 months beginning 01/31/2024 but did not include a rationale for the continuation of the medication. Based on record review and interview the facility failed to ensure that each resident was free from unnecessary medication use for 3 (#15, #60 and #122) of 6 (#15, #24, #34, #55, #60 and #122) residents reviewed for unnecessary medications. The facility failed to monitor for side effects and behaviors for residents #15 and #122 when administerd a psychotropic medication, and the physician failed to give a rationale for continuing a PRN psychotropic medication greater than 14 days for resident #60. Findings: Review of the facility's current policy on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and other irregularities, for example: d. inadequate monitoring for adverse consequences; 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services, standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. Resident #15 Review of the medical record for resident #15 revealed an admission date of 01/08/2024 with diagnoses including depression, atrial fibrillation, protein calorie malnutrition, and diabetes mellitus. Review of the care plan revealed resident #15 is at risk for side effects from antipsychotic drug use related to medication interactions. Further review of the care plan revealed the interventions were to monitor for side effects of psychotropic drugs such as blurred vision, mental confusion, worsening depression, and dizziness. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and required assistance with activities of daily living. Review of the physician's orders dated 01/08/2024 revealed an order for Zoloft (antidepressant) 25 milligrams (mg) per tube every day. Review of the Monthly Medication Review dated 01/26/2024 revealed the pharmacist recommended that the nurses need to document adverse effects and behaviors when administering Zoloft to resident #15. Review of the January 2024 and February 2024 Medication Administration Record (MAR) revealed no documented evidence that the facility was monitoring the resident's behaviors or medication side effects while receiving Zoloft. On 02/28/2024 at 11:30 a.m., an interview with S2Director of Nursing (DON) revealed the nurses failed to monitor for side effects and behaviors when resident #15 received Zoloft. Resident #122 Review of the medical record for resident #122 revealed diagnoses of hemiplegia, open angle glaucoma, depression, hypertension, cerebral infarction, anxiety, schizoaffective disorder, and dementia. Review of the care plan revealed resident #122 had psychosocial well-being including sad and crying, and to administer medications as ordered. Review of the admission MDS assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. Review of the physician's orders dated 02/07/2024 revealed an order for Zoloft 25 mg at bedtime. Review of the February 2024 MAR revealed no documented evidence that the facility was monitoring the resident's behaviors or medication side effects while receiving Zoloft. On 02/28/2024 at 11:45 a.m., an interview with S2DON revealed resident #122 was not being monitored for side effects and behaviors when administered Zoloft.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to electronically transmit encoded, accurate and complete MDS (Minimum Data Set) data to CMS (Centers for Medicare and Medicaid) in a timely manner for 1 (#35) of 3 (#35, 70, 71) residents reviewed for the completion of a 14 day discharge assessment. Record review revealed Resident # 35 was admitted to the facility on [DATE] and discharged on 10/27/2022. The last transmitted MDS assessment was a quarterly assessment completed on 09/13/2022. On 02/14/2023 at 10:10 a.m., an interview with S3 ADON (assistant director of nurses) confirmed the last MDS assessment was a quarterly assessment transmitted on 09/13/2022. S3 ADON confirmed a discharge assessment should have been completed and transmitted within 14 days of discharge. S3 ADON confirmed the MDS discharge assessment for Resident #35 was not completed, therefore it was not transmitted within a 14 day time period after the discharge date of 10/27/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents received services for UTI`s (urinary tract infections) by failing to obtain a physician's order to start antibiotic treatment for a UTI in a timely manner for 1 (#23) of 3 (#13, 23, 42) residents investigated for urinary catheter or UTI. Findings: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnosis that included hypertension, hip fracture and history of urinary tract infections. Resident #23 was continent of bowel and bladder. Review of the most recent completed quarterly MDS (minimum data set) dated 09/21/2022 revealed a BIMS (brief interview of mental status) score of 9 which indicated moderate cognitive impairment. Review of the nurses' notes revealed a urine sample was collected on the morning of 02/12/2023 and was sent to a laboratory on 02/13/2023 to determine if Resident #23 had a urinary tract infection. Review of the urinalysis lab results dated 02/14/2023 confirmed Resident #23 had a UTI. Review of the physician orders revealed a signed physician order dated 02/15/2023 for Macrodantin (antibiotic) to treat Resident #23`s urinary tract infection. On 02/13/2023 at 11:03 a.m., an interview with Resident # 23 revealed she had pain when urinating since 02/11/2023. Resident # 23 reported a urine sample was collected on 02/12/2023. On 02/15/2023 at 10:04 a.m., an interview with S4 LPN revealed she obtained the UA (urinalysis) results for Resident #23 sometime after 1:00 p.m. on 02/14/2023. S4 LPN faxed the lab results to Resident #23`s physician`s office on the afternoon of 02/14/2023 and got a confirmation that the physician`s office received the fax at 4:43 pm. S4 LPN confirmed neither the physician nor his office staff was called on 02/14/2023 in an effort to obtain orders for the treatment of Resident #23`s urinary tract infection. On 02/15/2023 at 10:37 a.m., an interview with S2 DON was conducted in her office. S2DON was informed the UA results for Resident # 23 were received on 02/14/2023 and confirmed Resident # 23 had a urinary tract infection. S2 DON was informed the lab results were faxed to the physician but no one spoke to the physician or office staff in an attempt to obtain orders to treat the urinary tract infection on 02/14/2023. S2 DON was informed the facility did not obtain an order to start antibiotics until 02/15/2023. S2 DON confirmed the facility should have called the physician or the physician`s office in an effort to begin treatment of the UTI on 02/14/2023.