Based on observations, record review, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (#152) of 1 sampled residents. Findings: Review of Self-Administration of medication policy and procedure with a revised date of 01/15/2024 revealed in part: As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. For self-administering resident, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken. Self-administered medications must be stored in a safe and secure place, which is not accessible by other resident. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medications to the resident when the resident requests them. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. Nursing staff will review the self-administered medication record on each nursing shift, and they will transfer pertinent information to the medication administration record kept at the nurse's station, appropriately noting that the doses were self-administered. Review of the record for resident #152 revealed an admit date of 10/21/2024 with diagnoses of amyotrophic lateral sclerosis (ALS) , depressive episodes, heart disease, type 2 diabetes, hypertension, sequelae of unspecified cerebrovascular diseases, and anxiety disorder. Review of the October 2024 Physician orders revealed: B complex vitamin 1 by mouth QD (every day), Fish oil 1 by mouth QD, Hydralazine HCL (Hydro Chloride) 25 milligrams (mg) by mouth BID (twice a day), Hydrochlorothiazide (HCTZ) 25mg by mouth QD, Hydrocodone-Tylenol 10-325mg 1 by mouth QD, Miralax 17grams (gm) powder by mouth QD, Novolog insulin per sliding scale before meals and bedtime, Radicava ORS oral suspension 105 mg/5milliliters (ml) 1 application by mouth every Monday, Rilutek 50mg (Riluzole) by mouth BID, Calcium 40mg by mouth at bedtime, Zoloft 50mg by mouth QD, Tamsulosin 0.4mg by mouth at bedtime, Toprol XL 50mg by mouth QD, Verapamil HCL ER (extended release) 120mg by mouth at bedtime, Vitamin C 1000mg by mouth QD, Vitamin D3 25microgram (mcg) by mouth QD, Coumadin 2.5mg give 3.75mg by mouth on Tuesday, Thursday and Saturday and 4.5 mg by mouth on Monday, Wednesday, Friday, and Sunday. Further review of the record and Physician orders revealed there were no orders for Fluticasone nasal spray 50mcg or Albuterol 90 mcg inhaler. On 10/28/2024 at 3:27 p.m., observation of a table at resident #152's bedside revealed a box of Fluticasone nasal spray 50 mcg with a label that read 2 sprays each nares every 12 hours as needed and an Albuterol 90 mcg inhaler without labeled instructions. Interview with resident #152 at this time revealed he does give himself these 2 medications. On 10/29/2024 at 2:04 p.m., observation again of resident #152's room revealed the same medications were still noted on the table at the resident's bedside. On 10/30/2024 at 2:01 p.m., an interview with S6Licensed Practical Nurse (LPN) revealed she removed the medications from resident #152's room this morning. S6 LPN confirmed resident #152 should not have had the medication at the bedside and should not have been taking the medications on his own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have documentation in the medical record regarding the need for a resident to be transferred to the hospital for 1 (#61) of 3 (#45, #61, #99) residents reviewed for hospitalization. Findings: Review of the Change in Condition policy and procedure dated 01/15/2024 in part revealed: 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the record for resident #61 revealed an original admission date of 09/18/2020 and a readmission date of 03/05/2024. Further review of the record for resident #61 revealed diagnoses of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery dated 03/05/2024, hypertension, somatoform disorder, gastrostomy, bladder disorder, anxiety disorder, dementia, chronic pain, sepsis, disorder of the adrenal, urinary tract infection, spinal stenosis, delusional disorders, and delirium. Review of the record revealed a discharge Minimum Data Set (MDS) assessment dated [DATE] and a return MDS assessment dated [DATE]. Review of the record for resident #61 revealed there was no documentation in the nurses' notes why resident #61 was discharged to the hospital on [DATE]. On 10/31/2024 at 8:30 a.m., an interview with S9Licensed Practical Nurse (LPN) revealed they do not document on anything to give to the family regarding transfers. S9LPN further revealed the only thing they do is call the family, send the medication list, Louisiana Physician Order for Scope of Treatment (LaPost) and face sheet with the resident. On 10/31/2024 at 8:34 a.m., an interview with S4Assistant Director of Nursing (ADON) confirmed there was no documentation in the record why resident #61 was sent to the hospital on [DATE]. S4ADON revealed the only notification the family received was a phone call and she confirmed there was no documentation in the record of resident #61's family being notified of the transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan and the preference of each resident to support residents in their choice of activities for 1 (#97) of 3 (#32, #42, and #97) residents reviewed for activities. Findings: Review of the record for resident #97 revealed an admit date of 07/22/2024 with diagnoses of hypertensive chronic kidney disease, chronic obstructive pulmonary disease, and type 2 diabetes. Review of the admission MDS (minimum data set) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Review of the activity assessment dated [DATE] for resident #97 revealed in part: C. When would you prefer to participate in scheduled activities? Any. 42C. Preferred activity setting- Any. The reason I am here- due to health issues. I am most happy when . I can get around/go to church. Review of the plan of care related to activities for resident #97 revealed in part: Cognitive impairment- ability to focus attention fluctuates. I need encouragement to attend activities- I am frequently tired with little energy. Will attend activities of my choice during the next review date. Allow me to express my feelings and desires. Encourage me to become involved in activities. Inform me of upcoming activities by: provide activity calendar, verbal reminders, escort, and encouragement. Praise involvement in activities. Review of the activity calendar for October 2024 for the week of 10/28/2024-10/31/2024 revealed: 10/28/2024- hand bells, bingo, coffee and chat 10/29/2024- pretty nails, bingo 10/30/2024- Bible Study with Mr. Porter, Bingo, Go Fish On 10/28/2024 at 2:27 p.m., observation of resident #97 throughout the day revealed the resident sat at a table with staff most of day. During the observations, staff were not interacting with resident #97 and there were no activities provided to resident #97. On 10/29/2024 at 1:45 p.m., observation of resident #97 revealed he was again sitting at the same table with no activities being provided. Review of the activity calendar revealed bingo was being played at 1:30 p.m. Further observation at that same time revealed S10Certified Nursing Aid (CNA) was sitting at the table eating food in front of the resident #97 and S11 CNA was standing at the table and food was noted to be in front of where she was standing. On 10/30/2024 at 8:30 a.m. and 10:00 a.m., observation of resident #97 revealed he was sitting at the same table in with no interaction. Review of the activity calendar for 10/30/2024 at 10:00 a.m. revealed Bible study was happening. On 10/30/2024 at 11:04 a.m., an interview with S12Activity revealed resident #97 liked to sit out on the hall, listen to music and will sometimes go to bingo and staff have to do the card for the resident at bingo. Further interview with S12Activity revealed she did not have any documentation of the specific activities that have been done with the resident #97. Review of the activity note in the computer dated 07/22/2024 by S12Activity revealed resident was an [AGE] year old widowed male that was admitted from home due to health issues. Resident Activity Director (RAD) goal is to offer in room/daily activities to help reduce any loneliness or boredom that may occur. Review of the activity note from 10/30/2024 at 7:58 a.m. revealed resident enjoys sitting in lobby, listening to music and getting visits from family. RAD goal is to continue to offer in room/daily activities to help reduce any loneliness or boredom that may occur. On 10/30/2024 at 11:34 a.m., an interview with resident #97 revealed he was very soft spoken but did say he would have liked to have gone to Bible study on 10/30/2024 at 10:00 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident received adequate supervision to remain as free of accident hazards as possible for 1 (#1) of 1 (#1) residents investigated for smoking. Findings: Review of the smoking policy with a date of 03/04/2024 revealed in part: Policy: It is the policy of this facility to enforce a smoke free environment within the facility for both residents and staff. As well as, to ensure the rights, safety, and well-being of all residents and staff are being respected. Procedure: Smoking procedures will be established and enforced for residents as a fire safety factor. The following guidelines include conditions under which smoking is permitted. 2. Residents may smoke only in designated areas so supervision of smoking may be enforced. 4. Residents who smoke will be assessed on admit, quarterly, and when there is a significant change in the resident's ability to handle their smoking products. 6. Assistance for smoking residents will be encouraged and provided based on the resident's needs and wishes. 8. Residents are not allowed to keep cigarettes, cigars, vape pens, vape chargers, nor lighters in their rooms. These items are to be kept at the nurses' station. Review of the record for resident #1 revealed diagnoses of diabetes, borderline intellectual functioning, tremor, unspecified dementia, psychotic disturbance, mood disturbance and anxiety, undifferentiated schizophrenia, and Parkinsonism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview Mental Status (BIMS) of 5 indicating resident #1 had severe cognitive impairment. Further review revealed resident #1 had problems with inattention and required substantial/maximal assistance with shower/bathing. Review of October 2024 Physician orders in part revealed resident #1 was prescribed: Abilify 10 milligrams (mg) every morning- for schizophrenia. Sinemet 10-100 mg, give 2 tabs twice a day for Parkinson's. Depakote 500 mg every morning and 250 mg every evening for bipolar disorder. Ativan 0.5 mg three times a day for anxiety. Chlorpromazine Hydrochloride (HCL)100 mg every evening for schizophrenia. Ingrezza 80 mg every evening for schizophrenia. Review of the current care plan revealed resident #1 was at risk for injury related to smoking. Further review revealed the resident digs in the ashtray for cigarette butts and picks up butts off ground. He constantly asked other residents/staff for cigarettes. The goal was for the resident to safely smoke in designated smoking areas. Further review of the resident's care plan revealed the following interventions: counsel on hazards of smoking in non-designated smoking areas, counsel resident on designated smoking areas and observe resident during smoking every shift. On 10/28/2024 9:05 a.m., observation of resident #1 revealed he was sitting outside in the smoking area. Resident #1 did not have a lit cigarette at that time. Surveyor walked in parking lot and returned to smoking area. At this time, resident #1 had a lit cigarette and the only staff in the area was the Environmental Supervisor, the laundry worker and the Maintenance Director. Interview with S13Maintenance Director stated that each resident is given 2 cigarettes and whatever staff is outside in the smoking area will light the cigarette for the resident. On 10/29/2024 at 2:45 p.m., observation of resident #1 revealed he was sitting in the smoking building by himself. Resident #1 said he had not smoked his cigarettes yet. An interview with S14Housekeeper who was outside near the smoking building said that any staff will light the cigarettes for resident #1. On 10/30/2024 at 2:21 p.m., an interview with S15Ward Clerk revealed S16Activity bags up the number of cigarettes for each resident per day and the bags of cigarettes were kept at the front desk. S15Ward Clerk further said that residents go to smoke at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. S15Ward Clerk said she will go outside with the resident and light the cigarette and any staff that is out near the smoking area can light the resident's cigarette. On 10/30/2024 at 3:13 p.m., review of the smoking assessment dated [DATE] revealed S4ADON completed the smoking assessment and scored resident #1 as a safe smoker. On 10/30/2024 at 3:18 p.m., an interview with S4ADON confirmed the assessment was not accurate, resident #1 should have been deemed an unsafe smoker and that resident #1 should have been monitored while smoking. At the same time, S2Corporate Director also said that if resident #1 was digging in the trash for cigarettes, picking butts off ground, or not extinguishing the cigarette correctly the resident is an unsafe smoker.

Based on record review and interview, the facility failed to ensure resident's drug regimens were free from unnecessary psychotropic medications for 1 (#93) of 5 (#50, #59, #68, #92, and #93) residents reviewed for unnecessary medications. The facility failed to ensure a psychotropic medication was used only when there was an acceptable diagnosis documented in the medical record for resident #93. Findings: Review of resident #93's record revealed an admission date of 09/04/2024 with diagnoses including unspecified dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, pain in unspecified joint, depression, hypothyroidism, edema, hyperlipidemia, and unspecified insomnia. Review of resident #93's October 2024 Physician's Orders revealed an order dated 09/04/2024 for Seroquel oral tablet 25 milligrams (mg) give 1 tablet by mouth (po) at hour of sleep (hs) with associated diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotropic disturbance, mood disturbance, psychotic disturbance, and anxiety. Review of the Pharmaceutical Consultant Report (Psychoactive Gradual Dose Reduction) for resident #93 dated 10/10/2024 revealed the pharmacist recommended the following -please provide an appropriate diagnosis for the use of Seroquel. Further review revealed the physician only addressed the request for the Gradual Dose Reduction (GDR) on 10/30/2024, but did not address the appropriate diagnosis for the use of Seroquel. Review of the record revealed resident #93 does not have an acceptable diagnosis for the use of Seroquel (psychotropic). An interview on 10/31/2024 at 10:55 a.m. with S3Director of Nursing (DON) confirmed the physician failed to document an acceptable diagnosis for the use of Seroquel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#42, #64, and #92) of 8 (#10, #18, #20, #27, #42, #64, #68, and #92) residents reviewed for restraints. The facility failed to ensure: 1). restraint consents were obtained which included risks and benefits of the restraint use for residents #42, #64, and #92; 2). physician orders were obtained for the lap trays for residents #64, and #92; and 3). monitoring was conducted for the release of the lap trays for residents #42, #64, and #92. Findings: Review of the facility Use of Restraints policy dated 01/12/2024 revealed the following, in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. When the use of restraints is indicated, the least restrictive will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative has consented to the treatment or procedure and the use of treatment restraints. 12. The following safety guidelines shall be implemented and documented while a resident is in restraints. a. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident. c. A resident placed in a restraint will be observed at least every 30 minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. d. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each 2 hours in which restraints are employed. e. Restrained residents must be repositioned at least every 2 hours on all shifts 14. Residents shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 19. Documentation regarding the use of restraints shall include: a. full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode; b. description of the resident's medical symptoms that warranted the use of restraints; c. how the restraint use benefits the resident by addressing the medical symptoms; d. the type of the physical restraint used; e. the length of effectiveness of the restraint time; and f. observation, range of motion and repositioning flow sheets. Resident #42 Review of the record revealed resident #42 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and muscle wasting and atrophy. Review of resident #42's October 2024 Physicians Orders revealed an order dated 07/14/2023 resident may be up in gerichair with lap tray when out of bed to promote mobility and socialization and an order dated 10/28/2024 to release laptray every 2 hours for 15 minutes and then reapply. Review of resident #42's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed no use of restraints and resident required partial/moderate assistance with activities of daily living. Review of resident #42's careplan dated 07/11/2023 with revision date of 09/17/2024 revealed potential for falls, required limited 2 person assist with transfers, wheelchair locomotion- resident may be up in gerichair with lap tray when out of bed to promote mobility. The interventions included: release lap tray every 2 hours for 15 minutes then reapply. Observations on 10/28/2024 at 10:04 a.m., 10/29/2024 at 9:30 a.m., and 10/31/2024 at 8:35 a.m. of resident #42 revealed resident was up in a gerichair with a lap tray in her room. Review of the Pre-Restraining assessment dated [DATE] revealed resident #42 may be up in gerichair for positioning and socialization. Further review of the record revealed no documented pre-restraining assessment prior to 07/14/2023 when a gerichair with lap tray was implemented for resident #42. Review of the Physical Restraint Elimination assessment dated [DATE] revealed a score of 35, indicating poor candidate for restraint reduction, less restrictive restraining measures, or total restraint elimination. Gerichair with lap tray, less restrictive measures to be used- no, additional comments- this device is not considered to be a restraint but to promote mobilization and socialization per Director of Nursing (DON). Review of the Consent for Assistive Devices for resident #42 dated 07/11/2023 revealed resident was at risk for injury. Further review revealed the consent did not specify specific restraint to be implemented (lap tray) and did not identify the risks/benefits for having a restraint. Review of the record for resident #42 revealed there was no documented evidence of the release of the lap tray every 2 hours prior to 10/28/2024. An interview on 10/30/2024 at 9:30 a.m. with S4Assistant Director of Nursing (ADON) revealed the facility did not have an order in place prior to 10/28/2024 for the release of the lap tray every 2 hours and confirmed resident #42 has had a gerichair with a lap tray since 07/14/2023. S4ADON further confirmed that resident #42 unable to release her lap tray. An interview on 10/31/2024 at 10:00 a.m. with S5ADON revealed the pre- restraining assessment for resident #42 was not completed prior to the implementation of the gerichair with lap tray on 07/14/2023. An interview on 10/31/2024 at 10:55 a.m. with S3Director of Nursing (DON) confirmed resident #42 has had a gerichair with lap tray since 07/14/2023. S3DON further confirmed the facility failed to have documentation of the release of the lap tray for resident #42 prior to 10/28/2024. S3DON confirmed the Pre-Restraining Assessment was not completed prior to implementing the gerichair with lap tray on 07/14/2023 for resident #42. S3DON confirmed the consent dated 07/11/2023 for use of assistive devices (which they use for restraints) does not identify the risks/benefits associated with the use of a restraint (gerichair with lap tray). Resident #64 Review of the medical record for resident #64 revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hypertensive heart disease, dementia in other diseases (mild with behavioral disturbance), and other lack of coordination. Review of the quarterly MDS assessment dated [DATE] revealed resident #64 had a BIMS score of 3 which indicated severe cognitive impairment for daily decision making and the resident required extensive to total assistance for most activities of daily living. Further review revealed a trunk restraint was not used. Review of resident #64's October 2024 physician's orders revealed no order for the use of a gerichair with a lap tray. On 10/28/2024 at 9:55 a.m., an observation of resident #64 revealed she was in her room sitting in a gerichair with a lap tray with her feet reclined. An interview with S7Certified Nursing Aide (CNA) at this time revealed the resident was unable to remove lap tray by herself. On 10/30/2024 at 8:55 a.m. and 10/30/2024 at 1:24 p.m., observations of resident #64 revealed she was sitting in a gerichair with a lap tray by the nurses' station. On 10/30/2024 at 1:50 p.m., an interview with S8CNA revealed she had not observed resident #64 take off her lap tray since she has worked with her. Review of the Pre-Restraining assessment dated [DATE] for resident #64 revealed she may be up in the gerichair with a lap tray for positioning and socialization. Further review revealed the lap tray was not identified as a restraint in the assessment. Review of resident #64's medical record revealed there was no documentation that a consent was obtained for the use of a gerichair with a lap tray. Further review revealed no documented evidence the resident and/or responsible party were informed of the potential risk and benefits of the use of lap tray per the facility policy. Further review of resident #64's medical record revealed no documented evidence of monitoring for the release of the lap tray at least every 2 hours. On 10/31/2024 at 3:00 p.m., an interview with S4ADON confirmed resident #64 did not have a physician's order or a consent for a gerichair with a lap tray. She also confirmed there was no documentation of monitoring for the release of the lap tray for resident #64. On 10/31/2024 at 12:45 p.m., an interview with S3DON confirmed resident #64 did not have a physician's order for a gerichair with lap tray. She also confirmed there was no documentation of monitoring for the release of the lap tray for resident #64. Resident #92 Review of the medical record revealed sample resident #92 was admitted to the facility on [DATE] with diagnosis that include diabetes mellitus, Psychotic disturbance, mood disturbance and anxiety, major depressive disorder, anxiety disorder, Parkinson's disease, hypertension, muscle spasm and aftercare following joint replacement surgery prior to admission. Further review of the medical record revealed the Significant change MDS dated [DATE] revealed the resident had a BIMS score of 3 which indicated the resident is cognitively impaired and needs assistance with all activities of daily living. Further review of the medical record revealed a pre-restraining assessment dated [DATE] which included a recommendation to use a gerichair with lap tray to promote mobility and socialization. Further review revealed, the lap tray was not identified as a restraint in the assessment. Review of resident #92's October 2024 physician's orders revealed no order for the use of a gerichair with a lap tray. On 10/28/2024 at 7:45 a.m., an observation of resident #92 revealed he was in the locked unit day room sitting in a gerichair with a lap tray. On 10/30/2024 at 8:55 a.m. and 10/30/2024 at 1:24 p.m., observations of resident #92 revealed he was sitting in a gerichair with a lap tray in the locked unit day room. Review of resident #92's medical record revealed there was no documentation that a consent was obtained for the use of a gerichair with a lap tray. Further review revealed no documented evidence the resident and/or responsible party were informed of the potential risk and benefits of the use of lap tray per the facility policy. Further review of resident #92's medical record revealed no documented evidence of monitoring for the release of the lap tray at least every 2 hours. On 10/31/2024 at 9:40 a.m., an interview with S4ADON confirmed resident #92 did not have a physician's order or a consent for a gerichair with lap tray. She also confirmed there was no documentation of monitoring for the release of the lap tray for resident #92. On 10/31/2024 at 11:15 a.m., an interview with S3DON confirmed resident #92 did not have a physician's order for a gerichair with lap tray. She also confirmed there was no documentation of a consent and monitoring for the release of the lap tray for resident #92.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #18 Review of resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, Alzheimer's disease, and anxiety disorder. Review of resident #18's MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated the resident was unable to complete the test. Further review revealed she required extensive assistance with bed mobility. An observation of resident #18 on 10/28/2024 at 9:11a.m. revealed she was lying in bed with a right quarter side rail that was raised. Observations of resident #18 on 10/29/2024 at 9:15 a.m. and 1:48 p.m. revealed she was lying in bed on her right side with the right quarter side rail raised. Review of resident #18's Consent for Assistive Devices revealed the facility failed to identify the assistive device implemented for the resident which was a right quarter side rail. Further review revealed the facility failed to inform the resident and/or the responsible party regarding the potential benefits and risks of the side rail use per the facility policy. An interview on 10/30/2024 at 3:00 p.m. with S4ADON confirmed the above consent for assistive devices did not identify the right quarter side rail use for resident #18. S4ADON also confirmed the potential risk and benefits of the side rail use were not included in the consent. Based on observations, interviews, and record reviews, the facility failed to ensure the residents' informed consent included the potential benefits and risks of the side rail use prior to installation for 2 (#18 and #22) of 2 (#18 and #22) residents identified for having side rails in use. Findings: Review of the facility's policy titled Physical Restraints, Side Rails dated 01/15/2024 revealed the following, in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 4. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 8. The risk and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. Resident #22 Review of resident #22's medical record revealed an admission date of 09/25/2022 with diagnosis of cardiac arrhythmia, heart disease, edema, osteoporosis, hypertension, dysphagia, and hearing loss. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicates the resident is cognitively aware and able to make daily decisions. Further review revealed the resident needs minimal assistance with activities of daily living. Observation of resident #22 on 10/28/2024 at 2:42 p.m. revealed she was lying in bed with bilateral quarter side rails raised. Observations of resident #22 on 10/29/2024 at 9:15 a.m. and 3:30 p.m. revealed she was lying in bed on her right side with the bilateral quarter side rails raised. Review of resident #22's Consent for Assistive Devices revealed the facility failed to identify the assistive device implemented for the resident which was bilateral quarter side rails. Further review revealed the facility failed to inform the resident and/or the responsible party regarding the potential benefits and risks of the side rail use per the facility policy. Interview on 10/30/2024 at 11:55 a.m. with S3Assistant Director of Nurses (ADON) confirmed resident #22 did not have a consent for the use of the side rails. Interview on 10/30/2024 at 12:00 p.m. with the S3Director of Nursing (DON) confirmed resident #22 did not have a consent for the use of the side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #50 Review of the record for resident #50 revealed an admission date of 03/13/2024 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, hypertension, edema, hyperlipidemia, neuralgia and neuritis, hypokalemia, other pulmonary embolism without acute cor pulmonale, Parkinson's disease with dyskinesia with fluctuations, anxiety disorder, Alzheimer's disease, and vascular dementia unspecified severity with mood disturbance. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. Review of resident #50's current Physician's Orders revealed the following orders: 07/13/2024- Lasix oral tablet 20 milligrams (mg) give 1 tablet 1 time a day; 03/13/2024- Losartan Potassium oral tablet 25 mg give 1 tablet by mouth (po) in the morning; 04/25/2024- Metoprolol Tartrate oral tablet 25 mg give 1 tablet po 2 times a day; 03/13/2024 Atorvastatin Calcium oral tablet 40 mg give 1 tablet po in the evening, Eliquis oral tablet 5 mg give 1 tab po 2 times a day, Gabapentin oral capsule 100 mg give 1 capsule po in the evening, Thiamine Hydrochloride (HCL) oral tablet 100 mg give 1 tab po in the morning, Potassium Chloride ER oral tablet extended release give 20 millequivalents (meq) po 1 time a day; 04/25/2024- Bumetanide oral tablet 1 mg give 1 tablet po 2 times a day; 05/22/2024- Celexa oral tablet give 20 mg po 1 time per day; 09/12/2024- Geodon oral capsule 20 mg give 20 mg po 1 time a day for combative behavior for 4 days; 09/16/2024- Geodon oral capsule 20 mg give 1 cap po in the morning; 05/26/2024- Risperidone oral tablet 1 mg give 1 tab po in the morning; 03/13/2024- Multivitamin oral tablet giv e 1 tablet po in the morning; 03/13/2024- Namenda oral tablet 5 mg give 1 tablet po 2 times a day; 03/13/2024- Vitamin C oral tablet give 1 tablet po 2 times a day; 03/13/2024- Nuplazid oral capsule 34 mg give 1 capsule po in the morning; 04/25/2024- Wellbutrin XL oral tablet extended release 24 hr 300 mg give 1 tablet po 1 time a day; 09/27/2024- Levofloxacin oral tablet 750 mg give 1 tablet po in the morning for 10 days; 07/17/2024- Nystatin External Powder 100000 unit/gram topical- apply to under breast and lower abdomen topically every day shift; 10/24/2024- Lasix oral tablet 20 mg give 1 tablet orally 2 times a day for edema to BLE 10/24/2024- Clindamycin Hydrochloride (HCL) oral capsule 300 mg give 300 mg po 3 times per day for 10 days Review of the September 2024 MAR revealed no documentation of medication administration for the following medications to resident #50: Atorvastatin Calcium- 4 times Celexa- 11 times Gabapentin- 4 times Geodon- 5 times Lasix- 11 times Levofloxacin- 1 time Losartan Potassium- 11 times Multivitamin- 11 times Nuplazid- 11 times Nystatin External powder- 1 time Thiamine- 11 times Potassium Chloride- 11 times Risperidone- 11 times Wellbutrin XL- 11 times Bumetanide - 15 times Eliquis- 15 times Vitamin C- 15 times Metoprolol Tartrate- 15 times Namenda- 15 times Review of the October 2024 MAR revealed no documentation of medication administration for the following medications to resident #50: Atorvastatin Calcium- 8 times Celexa- 5 times Gabapentin- 8 times Geodon- 5 times Lasix- 4 times Levofloxacin- 1 time Losartan Potassium-5 times MVI- 3 times Nuplazid- 3 times Nystatin External powder-3 times Thiamine- 3 times Potassium Chloride- 3 times Risperidone- 3 times Wellbutrin XL- 3 times Bumetanide - 8 times Eliquis- 8 times Vitamin C- 7 times Metoprolol Tartrate- 8 times Namenda- 7 times Lasix 20 mg bid- started 10/24/24- 3 times Clindamycin HCL started 10/24/2024- 3 times An interview on 10/30/2024 at 3:41 p.m. with S4Assistant Director of Nursing (ADON) revealed there was missing documentation of medication administration for resident #50 on the September and October 2024 MAR for multiple medications. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #50 on the September and October 2024 MAR. Resident #59 Review of resident #59's record revealed an admission date of 12/03/2021 with diagnoses including type 2 diabetes mellitus with unspecified complications, chronic obstructive pulmonary disease, chronic bronchitis, hypertension, hyperlipidemia, anemia, depression, cellulitis, dementia in other diseases classified elsewhere unspecified severity with agitation, generalized anxiety disorder, bipolar disorder, Alzheimer's disease, and peripheral vascular disease. Review of resident #59's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, which indicated severe cognitive impairment. Review of resident #59's current Physician's Orders revealed the following: 03/14/2023- Aricept oral tablet 10 milligrams (mg) give 1 tablet by mouth (po) 1 time a day, Melatonin tablet 3 mg give 3 m po at bedtime. 05/26/2022- Atorvastatin Calcium tablet 40 milligrams (mg) give 1 tablet at hour of sleep (hs) 04/10/2023- Dulera Aerosol 100-5 micrograms (mcg)/ACT 2 puffs inhale orally 2 times a day 04/24/2022- Eliquis tablet 2.5 mg give 1 tab po 2 times a day 12/22/2021- Metformin Hydrochloride (HCL) 500 mg give 500 mg po 2 times a day 10/12/2022- Quetiapine Fumarate (Seroquel) tablet 50 mg give 50 mg po 4 times a day 10/12/2022- Zyprexa tablet 2.5 mg give 2.5 mg po 2 times a day (bipolar disorder) 08/31/2022- Lubricant eye drops solution instill 1 drop in both eyes 3 times a day to right eye Review of the September 2024 MAR revealed no documentation for medication administration for the following medications on resident #59: Aricept- 3 times Atorvastatin Calcium-2 times Melatonin (3 mg - give 3 mg po at hs) - 2 times Dulera Aerosol- 2 times Eliquis- 2 times Iron tablet 325 mg (65 Fe, Ferrous Sulfate give 1 tab po 2 times a day- 04/27/22)- 2 times Metformin HCL- 2 times; Vitamin C (500 mg po 2 times a day- 08/09/23)- 2 times; Zyprexa- 2 times; Quetiapine Fumarate- 9 times; Lubricant eye drops solution (1 gtt en both eyes 3 times daily- 08/31/22)- 9 times; Review of the October 2024 MAR revealed no documentation for medication administration for the following medications on resident #59: Aricept- 3 times Atorvastatin Calcium- 3 times Melatonin (3 mg - give 3 mg po at hs) -3 times Dulera Aerosol- 3 times Eliquis- 2 times- 3 times Iron tablet 325 mg (65 Fe, Ferrous Sulfate give 1 tab po 2 times a day- 04/27/22)-3 times Metformin HCL-3 times Vitamin C (500 mg po 2 times a day- 3 times Zyprexa- 3 times Quetiapine Fumarate- 2 times Lubricant eye drops solution (1 drop in both eyes 3 times daily- 08/31/22)- 1 time An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #59 on the September and October 2024 MAR. Resident #93 Review of resident #93's record revealed an admission date of 09/04/2024 with diagnoses including unspecified dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, pain in unspecified joint, depression, hypothyroidism, edema, overactive bladder, hyperlipidemia, and unspecified insomnia. Review of resident #93's current Physician's Orders revealed the following orders dated 09/04/2024: Citalopram Hydrobromide oral tablet 20 milligrams (mg) give 1 tablet by mouth (po) in the morning, Lasix oral tablet 40 mg give 1 tablet po in the morning, Levothyroxine Sodium tablet 50 micrograms (mcg) give 1 tablet po in the morning, Seroquel oral tablet 25 mg give 1 tablet po at hour of sleep (hs), Simvastatin oral tablet 40 mg give 1 tablet po in the evening, Trazodone Hydrochloride (HCL) oral tablet 100 mg give 1 tablet po at hs, Oxybutynin chloride oral tablet 5 mg give 1 tablet po 2 times a day, Meloxicam oral tablet 15 mg give 1 po in the morning, Colace oral capsule 100 mg give 1 capsule po in the morning, and Donepezil Hydrochloride (HCL) oral tablet 5 mg give 1 tablet po at bedtime. Review of the September 2024 MAR revealed no documentation of medication administration for resident #93 for the following medications: Lasix- 13 times; Levothyroxine- 9 times; Meloxicam- 9 times; Seroquel- 4 times; Simvastatin- 4 times; Trazodone - 4 times; Oxybutynin Chloride- 13 times; Citalopram- 9 times; Colace- 9 times; Donepezil HCL- 4 times Review of the October 2024 MAR revealed no documentation of medication administration for resident #93 for the following medications: Lasix- 2 times Levothyroxine- 2 times Meloxicam- 2 times Seroquel- 5 times Simvastatin- 5 times Trazodone - 5 times Oxybutynin Chloride- 7 times Citalopram- 1 time Colace- 1 time Donepezil HCL- 5 times An interview on 10/31/2024 at 11:55 a.m. with S5Assistant Director of Nursing (ADON) confirmed the nurses failed to document administration of multiple medications to resident #93 on the September and October 2024 MAR. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #93 on the September and October 2024 MAR. Resident #17 Review of the medical record for resident #17 revealed he was admitted to the facility on [DATE] with diagnoses including enlarged prostate with lower urinary tract symptoms, overactive bladder, history of urinary tract infections, and long term use of antibiotics. Review of the quarterly MDS assessment dated [DATE] revealed resident #17 had a BIMS score of 9 which indicated he was moderately cognitively impaired for daily decision making and the resident required supervision with 1 person assistance for most activities of daily living (ADLs). Review of resident #17's October 2024 Physician's Orders revealed an order dated 05/20/2024 for Macrobid 100mg 1 by mouth daily. Review of resident #17's September 2024 and October 2024 MARs revealed the nurses failed to document multiple times that the resident's Macrobid 100mg was administered. Further review revealed a total of 3 times missed in September 2024 and 6 times missed in October 2024. On 10/31/2024 at 2:00 p.m., an interview with S4ADON revealed resident #17 received his Macrobid as ordered but they have had issues with some of the nurses not consistently documenting medications for the resident. The surveyor reviewed resident #17's September 2024 and October 2024 MARs with S4ADON. She confirmed the nurses failed to document the resident's Macrobid 100mg - 3 times in Sept. 2024 and 6 times in October 2024. On 10/31/2024 at 2:45 PM, S3DON confirmed resident #17's Macrobid documentation was inadequate for September 2024 and October 2024. S3DON revealed she recently had issues with some of the nurses not consistently documenting on the resident's MARs. Resident #83 Review of the medical record for resident #83 revealed she was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation and essential primary hypertension, Review of the quarterly MDS assessment dated [DATE] revealed resident #83 had a BIMS score of 8 which indicated she was moderately cognitively impaired for daily decision making and the resident required supervision with limited1 person assistance for most ADLs. Review of resident #83's October 2024 Physician's Orders revealed an order dated 02/26/2024 for Eliquis 2.5mg 1 po twice a day (BID). Further review revealed an order dated 05/28/2024 for bleeding precautions/monitoring every shift. Review of resident #83's September and October 2024 MARs revealed the nurses failed to document multiple times that the resident's Eliquis 2.5mg was administered. There was a total of 5 times missed for September 2024 and 12 times missed for October 2024. Further review revealed the nurses failed to consistently document monitoring for bleeding precautions. There was a total of 5 times missed for September 2024 and 7 times missed for October 2024. On 10/31/2024 at 2:00 p.m., an interview with S4ADON revealed resident #83 received her Eliquis 2.5mg po bid as ordered but they have had issues with some of the nurses not documenting medications for the resident. The surveyor reviewed resident #83's September 2024 and October 2024 MARs with S4ADON and she confirmed the nurses failed to document the above Eliquis administration and monitoring for bleeding as ordered. On 10/31/2024 at 2:45 PM, S3DON confirmed resident #83's Eliquis administration and monitoring for bleeding documentation was inadequate for September 2024 and October 2024. S3DON confirmed the nurses failed to document the above Eliquis administration and monitoring for bleeding as ordered. Based on record review and interview, the facility failed to ensure that nursing staff were able to demonstrate competencies and skills necessary to care for residents needs for 6 (#17, #50, #59, #68,#83, #93) of 6 (#17, #50, #59, #68,#83, #93) residents. The facility failed by not having documentation of medication administration daily. Resident #68 Review of the record for resident #68 revealed diagnoses of type 2 diabetes, dementia with other behavioral disturbances, depression, anxiety, congestive heart failure, and edema. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #68 had a Brief Interview Mental Status (BIMS) of 3 indicating the resident had severe cognitive impairment. Review of the September 2024 and October 2024 Physician orders revealed: Anti-anxiety medication side effects include drowsiness, confusion, nausea, weakness, delirium, disorientation, dizziness, impaired thinking, crying every shift. Anti-depressant side effects include: blurred vision, sedation, weight gain, gastrointestinal disturbance, dry mouth, constipation, urinary retention, headache, nausea, diarrhea, sleep disturbance every shift. Assess pain every shift using pain scale 0-10 every shift. Behavior/Mood monitoring every shift. Observe psychotropic medication side effects every shift. Apixaban 5mg (milligrams) by mouth twice a day. Atorvastatin Calcium 5mg by mouth every day. Cardizem CD extended release 24 hour 180 mg by mouth every day Doxazosin Mesylate 4mg by mouth at bedtime. Famotidine 20mg by mouth twice a day. Ferrous Sulfate 325mg by mouth every day. Flomax 0.4mg by mouth every day. Folic Acid 1mg by mouth every day. Insulin Lispro inject 10 units two times a day Klonopin 0.5 mg by mouth twice a day. Lasix 20mg by mouth every morning. Metformin HCL (Hydrochloride) 850 mg by mouth two times on 10/11/2024 the order was changed to Metformin 1000 mg by mouth twice a day. Namenda 10mg by mouth every day at bedtime. Polyethylene Glycol 17gm (gram) by mouth every day. Sennosides-Ducosate Sodium 8.6-50mg by mouth every day. Tradjenta 5mg by mouth every day. Tylenol 325mg give 2 tablets by mouth two times a day Vitamin C 250mg by mouth three times per day. Zoloft 50mg by mouth at bedtime. Review of the September 2024 Medication Administration Record (MAR) revealed no documentation of medication administration for the following medications to resident #68: Atorvastatin Calcium 5 times. Cardizem CD extended release 24 hour 180 mg 3 times. Doxazosin Mesylate 4mg 5 times. Ferrous Sulfate 325mg 3 times. Flomax 0.4mg 5 times. Folic Acid 1mg 3 times. Lasix 20mg 3 times. Namenda 10mg 5 times. Polyethylene Glycol 17gm 3 times. Sennosides-Ducosate Sodium 8.6-50 mg 3 times. Tradjenta 5mg 3 times Zoloft 50mg 5 times. Apixaban 5mg by mouth twice a day at 8:00 a.m. 3 times and at 6:00 p.m. 5 times. Famotidine 20mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Insulin Lispro inject 10 units two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Klonopin 0.5 mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Metformin HCL 850 mg by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Tylenol 325 mg give 2 tablets by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Vitamin C 250 mg by mouth three times per day at 8:00 a.m. 3 times, 12:00 p.m. 3 times and 6:00 p.m. 3 times. Assess pain every shift using the pain scale 0-10 every shift 4 times on day shift. Behavior/Mood monitoring to be monitored every shift 4 times on day shift. Anti-anxiety medication side effects monitoring 4 times on day shift. Antidepressant side effects monitoring 4 times on day shift. Bleeding precautions- assess for bleeding 4 times on day shift. Review of the October 2024 MAR from October 1- October 30, 2024 revealed: Atorvastatin Calcium 5mg 9 times; Cardizem CD extended release 24 hour 180 mg 8 times; Doxazosin Mesylate 4mg 10 times; Ferrous Sulfate 325mg 7 times; Flomax 0.4mg 9 times; Folic Acid 1mg 7 times; Lasix 20mg 7 times; Namenda 10mg 9 times; Polyethylene Glycol 17gm 7 times; Sennosides-Ducosate Sodium 8.6-50 mg 7 times; Tradjenta 5mg 7 times; Zoloft 50mg 9 times; Apixaban 5mg by mouth twice a day at 8:00 a.m. 8 times and 6:00 p.m. 9 times; Famotidine 20mg by mouth twice a day at 8:00 a.m. 7 times and 6:00 p.m. 7 times; Insulin Lispro inject 10 units two times a day at 8:00 a.m. 9 times and 6:00 p.m. 10 times; Klonopin 0.5mg by mouth twice a day at 8:00 a.m. 8 times and 6:00 p.m. 9 times; Metformin HCL 850 mg by mouth two times a day at 8:00 a.m. 3 times and 6:00 p.m. 2 times; Metformin HCL 1000 mg by mouth two times a day with a start date of 10/11/2024 6 of 19 days at 6:00 p.m.; Tylenol 325 mg 2 tablets two times a day 8:00 a.m. 7 times and 6:00 p.m. 9 times; Vitamin C 250 mg by mouth three times per day at 8:00 a.m. 7 times, 12:00 p.m. 7 times and 6:00 p.m. 9 times. Assess pain every shift using the pain scale 0-10 every shift 11 times on day shift; Behavior/Mood monitoring to be monitored every shift revealed 11 times on day shift; Anti-anxiety medication side effects monitoring twice a day 10 times on day shift; Antidepressant side effects monitoring twice a day 10 times on day shift; Bleeding precautions- assess for bleeding on the day shift and night shift. 10 times on day shift. On 10/31/2024 at 2:45 p.m., S3Director of Nursing (DON) confirmed the above documentation was inadequate on the September and October 2024 MAR for resident #68.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #50 Review of the record for resident #50 revealed an admission date of 03/13/2024 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, hypertension, edema, hyperlipidemia, neuralgia and neuritis, hypokalemia, other pulmonary embolism without acute cor pulmonale, Parkinson's disease with dyskinesia with fluctuations, anxiety disorder, Alzheimer's disease, and vascular dementia unspecified severity with mood disturbance. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of resident #50's current Physician's Orders revealed the following orders: 07/13/2024- Lasix oral tablet 20 milligrams (mg) give 1 tablet 1 time a day; 03/13/2024- Losartan Potassium oral tablet 25 mg give 1 tablet by mouth (po) in the morning; 04/25/2024- Metoprolol Tartrate oral tablet 25 mg give 1 tablet po 2 times a day; 03/13/2024 Atorvastatin Calcium oral tablet 40 mg give 1 tablet po in the evening, Eliquis oral tablet 5 mg give 1 tab po 2 times a day, Gabapentin oral capsule 100 mg give 1 capsule po in the evening, Thiamine Hydrochloride (HCL) oral tablet 100 mg give 1 tab po in the morning, Potassium Chloride ER oral tablet extended release give 20 millequivalents (meq) po 1 time a day; 04/25/2024- Bumetanide oral tablet 1 mg give 1 tablet po 2 times a day; 05/22/2024- Celexa oral tablet give 20 mg po 1 time per day; 09/12/2024- Geodon oral capsule 20 mg give 20 mg po 1 time a day for combative behavior for 4 days; 09/16/2024- Geodon oral capsule 20 mg give 1 cap po in the morning; 05/26/2024- Risperidone oral tablet 1 mg give 1 tab po in the morning; 03/13/2024- Multivitamin oral tablet give 1 tablet po in the morning; 03/13/2024- Namenda oral tablet 5 mg give 1 tablet po 2 times a day; 03/13/2024- Vitamin C oral tablet give 1 tablet po 2 times a day; 03/13/2024- Nuplazid oral capsule 34 mg give 1 capsule po in the morning; 04/25/2024- Wellbutrin XL oral tablet extended release 24 hr 300 mg give 1 tablet po 1 time a day; 09/27/2024- Levofloxacin oral tablet 750 mg give 1 tablet po in the morning for 10 days; 07/17/2024- Nystatin External Powder 100000 unit/gram topical- apply to under breast and lower abdomen topically every day shift. Review of the September 2024 Medication Administration Record (MAR) revealed no documentation of medication administration for the following medications to resident #50: Atorvastatin Calcium- 4 times Celexa- 11 times Gabapentin- 4 times Geodon- 5 times Lasix- 11 times Levofloxacin- 1 time Losartan Potassium- 11 times Multivitamin- 11 times Nuplazid- 11 times Nystatin External powder- 1 time Thiamine- 11 times Potassium Chloride- 11 times Risperidone- 11 times Wellbutrin XL- 11 times Bumetanide - 15 times Eliquis- 15 times Vitamin C- 15 times Metoprolol Tartrate- 15 times Namenda- 15 times Review of the Pharmaceutical Consultant Report dated 10/10/2024 revealed no documented evidence that the pharmacist identified the irregularities regarding the September 2024 MAR having multiple medications not documented as administered for resident #50. An interview with S3Director of Nursing (DON) on 10/30/2024 at 2:56 p.m. confirmed no documentation of administration of multiple medications listed above for resident #50 on the September 2024 MAR. An interview on 10/30/2024 at 3:41 p.m. with S4Assistant Director of Nursing (ADON) revealed there was missing documentation of medication administration for resident #50 on the September MAR for multiple medications. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #50 on the September MAR. S3DON confirmed the pharmacist failed to notify the DON/Physician/facility regarding irregularities from the September 2024 MAR for resident #50. Resident #59 Review of resident #59's record revealed an admission date of 12/03/2021 with diagnoses including type 2 diabetes mellitus with unspecified complications, chronic obstructive pulmonary disease, chronic bronchitis, hypertension, hyperlipidemia, anemia, depression, cellulitis, dementia in other diseases classified elsewhere unspecified severity with agitation, generalized anxiety disorder, bipolar disorder, Alzheimer's disease, and peripheral vascular disease. Review of resident #59's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Review of resident #59's current Physician's Orders revealed the following: 03/14/2023- Aricept oral tablet 10 milligrams (mg) give 1 tablet by mouth (po) 1 time a day, Melatonin tablet 3 mg give 3 mg po at bedtime. 05/26/2022- Atorvastatin Calcium tablet 40 milligrams (mg) give 1 tablet at hour of sleep (hs) 04/10/2023- Dulera Aerosol 100-5 micrograms (mcg)/ACT 2 puffs inhale orally 2 times a day 04/24/2022- Eliquis tablet 2.5 mg give 1 tab po 2 times a day 12/22/2021- Metformin Hydrochloride (HCL) 500 mg give 500 mg po 2 times a day 10/12/2022- Quetiapine Fumarate (Seroquel) tablet 50 mg give 50 mg po 4 times a day 10/12/2022- Zyprexa tablet 2.5 mg give 2.5 mg po 2 times a day (bipolar disorder) 08/31/2022- Lubricant eye drops solution instill 1 drop in both eyes 3 times a day Review of the September 2024 Medication Administration Record (MAR) revealed no documentation for medication administration for the following medications on resident #59 in September: Aricept- 3 times Atorvastatin Calcium-2 times Melatonin (3 mg - give 3 mg po at hs) - 2 times Dulera Aerosol- 2 times Eliquis- 2 times Iron tablet 325 mg (65 Fe, Ferrous Sulfate give 1 tab po 2 times a day- 04/27/22)- 2 times Metformin HCL- 2 times; Vitamin C (500 mg po 2 times a day- 08/09/23)- 2 times; Zyprexa- 2 times; Quetiapine Fumarate- 9 times; Lubricant eye drops solution (1 gtt in both eyes 3 times daily- 08/31/22)- 9 times; Review of the Pharmaceutical Consultant Report dated 10/10/2024 revealed no documented evidence that the pharmacist identified the irregularities regarding the September 2024 MAR having multiple medications not documented as administered for resident #59. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #59 on the September MAR. S3DON confirmed the pharmacist failed to notify her/the facility/physician regarding the irregularities from the September 2024 MAR for resident #59. Resident #93 Review of resident #93's record revealed an admission date of 09/04/2024 with diagnoses including unspecified dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, pain in unspecified joint, depression, hypothyroidism, edema, overactive bladder, hyperlipidemia, and unspecified insomnia. Review of resident #93's current Physician's Orders revealed the following orders dated 09/04/2024: Citalopram Hydrobromide oral tablet 20 milligrams (mg) give 1 tablet by mouth (po) in the morning, Lasix oral tablet 40 mg give 1 tablet po in the morning, Levothyroxine Sodium tablet 50 micrograms (mcg) give 1 tablet po in the morning, Seroquel oral tablet 25 mg give 1 tablet po at hour of sleep (hs), Simvastatin oral tablet 40 mg give 1 tablet po in the evening, Trazodone Hydrochloride (HCL) oral tablet 100 mg give 1 tablet po at hs, Oxybutynin chloride oral tablet 5 mg give 1 tablet po 2 times a day, Meloxicam oral tablet 15 mg give 1 po in the morning, Colace oral capsule 100 mg give 1 capsule po in the morning, and Donepezil Hydrochloride (HCL) oral tablet 5 mg give 1 tablet po at bedtime. Review of the September 2024 MAR revealed no documentation of medication administration for the following: Lasix- 13 times; Levothyroxine- 9 times; Meloxicam- 9 times; Seroquel- 4 times; Simvastatin- 4 times; Trazodone - 4 times; Oxybutynin Chloride- 13 times; Citalopram- 9 times; Colace- 9 times; Donepezil HCL- 4 times Review of the Pharmaceutical Consultant Report dated 10/10/2024 revealed no documented evidence that the pharmacist identified the irregularities regarding the September 2024 MAR having multiple medications not documented as administered for resident #93. An interview on 10/31/2024 at 11:55 a.m. with S5ADON confirmed nurses failed to document administration of multiple medications to resident #93 for September 2024. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #93 on the September MAR. S3DON confirmed the pharmacist failed to notify her/the facility/physician regarding irregularities from the September 2024 MAR for resident #93. Resident #17 Review of the medical record for resident #17 revealed he was admitted to the facility on [DATE] with diagnoses including enlarged prostate with lower urinary tract symptoms, overactive bladder, history of urinary tract infections, and long term use of antibiotics. Review of the quarterly MDS assessment dated [DATE] revealed resident #17 had a BIMS score of 9 which indicated he was moderately cognitively impaired for daily decision making and the resident required supervision with 1 person assistance for most activities of daily living (ADLs). Review of resident #17's October 2024 Physician's Orders revealed an order dated 05/20/2024 for Macrobid 100mg 1 by mouth daily. Review of resident #17's September 2024 MAR revealed the nurses failed to document 3 times that the resident's Macrobid 100mg was administered. Review of the Medication Regimen Review (MRR) dated 10/10/2024 (review was for previous month, September 2024) for resident # 17 revealed the pharmacy consultant failed to identify the nurses above incomplete documentation of the administration of Macrobid 100mg on the September 2024 MAR. On 10/31/2024 at 2:45 PM, S3DON confirmed the pharmacy consultant failed to address the above missed documentation of Macrobid on the September 2024 MAR for resident #17. Resident #83 Review of the medical record for resident #83 revealed an admit date of 01/04/2023 with diagnoses including paroxysmal atrial fibrillation and essential primary hypertension. Review of the quarterly MDS assessment dated [DATE] revealed resident #83 had a BIMS score of 8 which indicated she was moderately cognitively impaired for daily decision making and the resident required supervision with limited 1 person assistance for most ADLs. Review of resident #83's October 2024 Physician's Orders revealed an order dated 02/26/2024 for Eliquis 2.5mg 1 po twice a day. Further review revealed an order dated 05/28/2024 for bleeding precautions/monitoring every shift. Review of resident #83's September MAR revealed the nurses failed to document 5 times that the resident's Eliquis 2.5mg was administered. Further review revealed the nurses failed to consistently document monitoring for bleeding precautions. There was a total of 5 times missed for September 2024. On 10/31/2024 at 2:45 PM, S3DON confirmed the pharmacy consultant failed to address the above missed documentation for Eliquis administration and monitoring for bleeding for resident #83 on the September 2024 MAR. Based on record reviews and interviews, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director, and the director of nursing. The pharmacist failed to identify the nurses' incomplete medication administration documentation for 4 (#50, #59, #68, and #93) of 5 (#50, #59, #68, #92, and #93) sampled residents reviewed for unnecessary medications, 1 (#17) of 1 sampled resident reviewed for an antibiotic medication, and 1 (#83) of 1 sampled resident reviewed for an anticoagulant medication. Findings: Resident #68 Review of the record for resident #68 revealed diagnoses of type 2 diabetes, dementia with other behavioral disturbances, depression, anxiety, congestive heart failure, and edema. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #68 had a Brief Interview Mental Status (BIMS) of 3 indicating the resident had severe cognitive impairment. Review of the September 2024 and October 2024 Physician orders revealed: Anti-anxiety medication side effects include drowsiness, confusion, nausea, weakness, delirium, disorientation, dizziness, impaired thinking, crying every shift. Anti-depressant side effects include: blurred vision, sedation, weight gain, gastrointestinal disturbance, dry mouth, constipation, urinary retention, headache, nausea, diarrhea, sleep disturbance every shift. Assess pain every shift using pain scale 0-10 every shift. Behavior/Mood monitoring every shift. Observe psychotropic medication side effects every shift. Apixaban 5mg (milligrams) by mouth twice a day. Atorvastatin Calcium 5mg by mouth every day. Cardizem CD extended release 24 hour 180 mg by mouth every day Doxazosin Mesylate 4mg by mouth at bedtime. Famotidine 20mg by mouth twice a day. Ferrous Sulfate 325mg by mouth every day. Flomax 0.4mg by mouth every day. Folic Acid 1mg by mouth every day. Insulin Lispro inject 10 units two times a day Klonopin 0.5 mg by mouth twice a day. Lasix 20mg by mouth every morning. Metformin HCL (Hydrochloride) 850 mg by mouth two times on 10/11/2024 the order was changed to Metformin 1000 mg by mouth twice a day. Namenda 10mg by mouth every day at bedtime. Polyethylene Glycol 17gm (gram) by mouth every day. Sennosides-Ducosate Sodium 8.6-50mg by mouth every day. Tradjenta 5mg by mouth every day. Tylenol 325mg give 2 tablets by mouth two times a day Vitamin C 250mg by mouth three times per day. Zoloft 50mg by mouth at bedtime. Review of the September 2024 Medication Administration Record (MAR) revealed no documentation of medication administration for the following medications to resident #68 during September: Atorvastatin Calcium 5 times. Cardizem CD extended release 24 hour 180 mg 3 times. Doxazosin Mesylate 4mg 5 times. Ferrous Sulfate 325mg 3 times. Flomax 0.4mg 5 times. Folic Acid 1mg 3 times. Lasix 20mg 3 times. Namenda 10mg 5 times. Polyethylene Glycol 17gm 3 times. Sennosides-Ducosate Sodium 8.6-50 mg 3 times. Tradjenta 5mg 3 times Zoloft 50mg 5 times. Apixaban 5mg by mouth twice a day at 8:00 a.m. 3 times and at 6:00 p.m. 5 times. Famotidine 20mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Insulin Lispro inject 10 units two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Klonopin 0.5 mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Metformin HCL 850 mg by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Tylenol 325 mg give 2 tablets by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Vitamin C 250 mg by mouth three times per day at 8:00 a.m. 3 times, 12:00 p.m. 3 times and 6:00 p.m. 3 times. Assess pain every shift using the pain scale 0-10 every shift 4 times on day shift. Behavior/Mood monitoring to be monitored every shift 4 times on day shift. Anti-anxiety medication side effects monitoring 4 times on day shift. Antidepressant side effects monitoring 4 times on day shift. Bleeding precautions- assess for bleeding 4 times on day shift. Review of the October 2024 Pharmacy Consultant report revealed the pharmacist did not identify/address the incomplete documentation by the nurses on the September 2024 MAR. On 10/31/2024 at 2:45 p.m., S3Director of Nursing (DON) confirmed the above incomplete documentation was inadequate for resident #68's September 2024 MAR. S3DON further confirmed the Pharmacy Consultant did not address the missing documentation in the October 2024 drug regimen review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure residents who were unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to ensure resident's fingernails were trimmed and cleaned in a timely manner for 1 (#49) of 2 (#49, #54) residents reviewed for activities of daily living. Findings: Review of Resident #49's medical record revealed an admission date of 04/25/2023 with diagnosis of heart disease with heart failure, depression, chronic obstructive pulmonary disease, anxiety, fluid overload, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has a BIMS (Brief Interview for Mental Status) score of 5 which indicated the resident was cognitively impaired and unable to make daily decisions. Further review revealed the resident required physical assistance with all activities of daily living. Review of the residents current care plan revealed the Certified Nursing Assistants (CNAs) are responsible for cleaning and cutting resident #49's fingernails. Observation on 11/13/2023 at 11:05 a.m., 11/14/2023 at 10:50 a.m., 11/14/2023 at 3:30 p.m. and 11/15/2023 at 8:15 a.m. revealed resident #49 had long dirty unkept fingernails. Interview on 11/15/2023 at 8:30 a.m., with S5CNA stated the nurses cut and clean the resident's nails when they are in need of cutting and cleaning. Interview on 11/15/2023 at 1:22 p.m., with the S4Licensed Practical Nurse (LPN) stated sample resident #49 is not a diabetic and the CNAs are responsible for cutting and cleaning the residents nails as long as they are not diabetic. Interview on 11/15/2023 at 2:30 p.m. with S2Director of Nursing (DON) confirmed the CNAs are responsible for cutting and cleaning the residents nails as long as they don't have a diagnosis of diabetes and Resident #49 doesn't have diabetes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the pharmacist failed to report any irregularities to the attending physician, facility's medical director, and director of nursing by failing to report lab not obtained as ordered for 1 (#68) of 5 (#47, #63, #68, #100, and #259) sampled residents reviewed for unnecessary medications. The pharmacist failed to identify that the facility failed to obtain a Fasting Lipid Panel (FLP) for resident #68 yearly. Findings: Resident #68 Review of the medical record revealed resident #68 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, dementia, depression, anxiety, hypothyroidism, and hypertension. Review of the current care plan revealed the resident was at risk for abnormal labs and to draw labs as ordered. Review of the physician's orders dated 05/04/2022 revealed an order to obtain a FLP yearly. Review of the medical record revealed no documented evidence of a FLP drawn yearly as ordered. Review of the Medication Regimen Review dated 07/05/2023, 08/03/2023, 09/06/2023, and 10/10/2023 revealed the pharmacist did not address the FLP was not drawn yearly in May 2023 as ordered. On 11/15/2023 at 2:20 p.m. interview with S2Director of Nursing (DON) revealed the pharmacist did not inform her that resident #68's FLP had not be drawn in May 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to obtain laboratory testing as ordered by the physician for 1 (#68) of 5 (#47, #63, #68, #100, and #259) residents reviewed for laboratory services. The facility failed to draw a Fasting Lipid Panel (FLP) yearly for resident #68. Findings: Resident #68 Review of the medical record revealed resident #68 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, dementia, depression, anxiety, hypothyroidism, and hypertension. Review of the current care plan revealed the resident was at risk for abnormal labs and to draw labs as ordered. Review of the physician's orders dated 05/04/2022 revealed an order to obtain a FLP yearly. Review of the medical record revealed no documented evidence of a FLP drawn yearly as ordered. On 11/15//2023 at 2:20 p.m. interview with S6Assistant Director of Nursing (ADON) revealed the FLP for resident #68 was not drawn yearly as ordered.

Based on record reviews and interviews, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's need by not having: 1) Documented evidence of wound care completed for resident #83 as ordered; and 2) Documented evidence of medications administered to resident #100 on 11/13/2023 as ordered. Findings: Resident #83 Review of the facility's current Charting and Documentation Policy and Procedure revealed in part the following: Rules for Charting and Documentation 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medications, etc., as well as routine observations. 2. Be concise, accurate, complete and use objective terms. 5. Document daily treatments, vital signs, etc. Review of the record for resident #83 revealed an admission date of 04/28/2022 with diagnoses including acute post hemorrhagic anemia, idiopathic peripheral autoimmune neuropathy, periapical abscess without sinus, and nontraumatic subarachnoid hemorrhage, and tinea unguium. Review of Physician's Progress Notes revealed the following orders: -09/25/2023- discontinue Fluorouracil for now, restart twice a day (bid) applications in 2 weeks (10/09/2023); and -11/06/2023- discontinue Fluorouracil, continue Vaseline applications at nighttime, gently wash scalp with dove soap nightly. Review of resident #83's October 2023 Treatment Administration Record (TAR) revealed no documented evidence that the Flourouracil cream treatment to the scalp bid was completed 30 times from 10/09/2023-10/31/2023. Review of resident #83's November 2023 TAR revealed no documented evidence that the Flourouracil cream treatment to the scalp bid was completed 7 times from 11/01/2023-11/07/2023. Further review of the TAR revealed no documentation of washing the scalp with Dove soap nightly and applying Vaseline to the scalp every night 4 times from 11/07/2023-11/15/2023. An interview on 11/15/2023 at 11:25 a.m. with S3Licensed Practical Nurse (LPN)/Treatment Nurse revealed no documented evidence treatments were completed as ordered bid and nightly for resident #83 for October and November 2023. An interview on 11/15/2023 at 3:15 p.m. with S2DON confirmed no documented evidence that the treatments were completed as ordered for resident #83. S2DON further confirmed there was no documented evidence of Flourouracil treatments 30 times in October 2023, and 7 times in November 2023. S2DON confirmed no documentation of nightly Dove soap and Vaseline 4 times in November 2023. Resident #100 Review of the medical record for resident #100 revealed diagnoses of Non-Hodgkin's Lymphoma, reflux, seizure disorder, hypokalemia, hypertension, depression, constipation, polycythemia, and obesity. Review of the care plan revealed the resident was at risk for the following: abnormal labs, injury related to seizures, hypertension and resident #100 had the potential for excessive weakness and fatigue. Review of the approaches were to administer medication as ordered. Review of the November 2023 Medication Administration Record (MAR) revealed no documented evidence the evening medications were administered on November 13, 2023. On 11/15/2023 at 3:20 p.m. interview with S7Licensed Practical Nurse (LPN) that worked 11/13/2023 revealed the computers were not working and she was unable to sign the electronic Medication Administration Record and she did not use a paper MAR. On 11/14/2023 at 4:10 p.m. an interview with S6Assistant Director of Nursing (ADON) revealed when the computer electronic MAR is not working the LPNs are to use a paper MAR. S6ADON confirmed there was no documentation that S7LPN administered medications to resident #100 on 11/13/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to assure that each resident receives an accurate assessment by failing to identify a skin issue on a weekly body audit for 1 (Resident #3) of 3 (Resident #3, #4, and #6) residents sampled for weekly body audits. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, anemia due to glucose 6 phosphate dehydrogenase deficiency, acute respiratory failure with hypoxia, , gastrointestinal hemorrhage, hypokalemia, chronic obstructive pulmonary disease, hypertension, age related cognitive decline, hyperlipidemia, edema, gastroesophageal reflux, enlarged prostate with lower urinary tract symptoms, and lobar pneumonia. Review of the Medicare 5 day MDS (Minimum Data Set) dated 05/23/2023 revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderate cognitive impairment. Resident #3 requires limited assistance with 2 person physical assist for bed mobility and transfers, supervision with setup assist for eating, and extensive assistance with 1 person physical assist for toileting. Further review of the MDS revealed the resident was always continent of bowel and bladder. Review of the June 2023 Physician's Orders for resident #3 revealed no orders for treatment to right heel. An interview and observation of resident #3 on 06/05/2023 at 11:35 a.m. revealed he removed both of his socks and the following was noted: left lower leg edematous with taut reddened skin which went from mid shin to toes, and right lower leg edematous from ankle to toes, reddened area to the top of right foot and an open area to the right heel. Resident #3 reported he has had some weeping from his lower legs and he has made staff aware of the pain in his feet. Resident #3 further reported the staff have looked at his lower extremities. Observation at this time revealed no dressing was in place to bilateral lower extremities. On 06/05/2023 at 2:30 p.m., an interview with resident #3 revealed he has had swelling to bilateral lower extremities since he was admitted . Review of the daily skilled note for resident #3 dated 05/31/2023 revealed resident #3 had no skin problems identified and no edema noted by S6LPN (Licensed Practical Nurse). Review of the 04/18/2023 care plan for resident #3 revealed potential for impaired skin integrity related to activity of daily living self-deficit/occasional bowel and bladder incontinence- apply barrier cream as needed, Braden risk assessment per facility protocols, keep resident clean, dry, encourage adequate nutrition and hydration. Review of the Risk Assessments Policy and Procedure revealed the MDS nurse or charge nurse will complete the following risk assessments: -Braden scale to be completed by MDS nurse or charge nurse on admission and quarterly. -Braden scale determines resident's risks for skin impairment (complete on admit, then weekly for 4 weeks, then quarterly). -Body audit- complete on admit and readmission each week for 4 weeks. Continue weekly body audits for resident who have a Braden score of 12 or less and those who have pressure ulcers. An interview on 06/06/2023 at 9:50 a.m. with S10Treatment RN (Registered Nurse) revealed resident #3 does not have any wounds/skin issues. S10Treatment RN reported skin assessments done weekly on resident #3. An interview on 06/06/2023 at 10:05 a.m. with S2DON (Director of Nursing) revealed resident #3 does not have any wounds/skin issues. S2DON also reported resident #3 has weekly skin assessments done by hall nurses or treatment nurse. Review of the weekly body audits for resident #3 from April 2023 through June 2023 revealed S10Treatment RN completed all weekly body audits. Further review of the body audits revealed no skin breakdown was identified for resident #3 for the body audits done on 04/18/2023, 04/25/2023, 05/02/2023, 05/09/2023, 05/16/2023, 05/23/2023, 05/30/2023, and 06/06/2023. On 06/06/2023 at 10:45 a.m., S2DON and S10Treatment RN accompanied surveyor to resident #3's room for evaluation of resident's bilateral lower extremities. S2DON and S10Treatment RN both confirmed resident #3 had a scab to right heel, edema and redness to bilateral lower extremities, and had pain to bilateral lower extremities. Review of the weekly body audit and nurse's note for resident #3 dated 06/06/2023 revealed that the resident had a tear on the right heel measuring 1.5 cm (centimeters) by 0.2 cm by 0.1 cm, no exudate noted, periwound red and dry, expressed pain when area is touched. S10Treatment RN notified the resident's physician on 06/06/2023 at 10:50 a.m. of resident's heel and of redness/swelling noted to bilateral lower extremities. The physician ordered to obtain CBC (Complete Blood Count), CMP (Complete Metabolic Panel), blood cultures times 2, and start resident on Clindamycin 300 mg (milligrams) tid (3 times per day) for 10 days, and apply betadine bid (2 times per day) to right heel. An interview on 06/06/2023 at 12:00 p.m. with S3Corporate Administrator revealed resident #3's Braden scale dated 04/18/2023 had a score of 20 indicating not at risk for pressure ulcers. An interview on 06/07/2023 at 3:02 p.m. with S2DON confirmed the weekly body audit completed on 06/06/2023 for resident #3 by S10Treatment RN was an inaccurate assessment. S2DON reported that weekly skin assessment/body audit for 06/06/2023 revealed resident #3 had no skin breakdown, but based on observation on 06/06/2023 at 10:45 a.m. resident #3 has edema and redness to bilateral lower extremities, and a skin tear to right heel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide pain management consistent with professional standards of practice for1 (Resident #3) of 6 (Resident #1, #2. #3. #4, #5, and #6) sampled residents. The facility failed to administer pain medication to resident #3 after he complained of having pain. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, anemia due to glucose 6 phosphate dehydrogenase deficiency, acute respiratory failure with hypoxia, , gastrointestinal hemorrhage, hypokalemia, chronic obstructive pulmonary disease, hypertension, age related cognitive decline, hyperlipidemia, edema, gastroesophageal reflux, enlarged prostate with lower urinary tract symptoms, and lobar pneumonia. Review of the Medicare 5 day MDS (Minimum Data Set) dated 05/23/2023 revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderate cognitive impairment. Resident #3 requires limited assistance with 2 person physical assist for bed mobility and transfers, supervision with setup assist for eating, and extensive assistance with 1 person physical assist for toileting. The pain management section of the MDS revealed resident #3 did not receive scheduled pain medication regimen or prn (as needed) pain medication or was offered and declined, and no pain identified on MDS for the last 5 day look back period. Review of the June 2023 Physician's Orders for resident #3 revealed no orders for pain medication. An interview on 06/05/2023 at 11:35 a.m. with resident #3 revealed he has a lot of pain with bilateral feet and he has notified staff of this but not currently on pain medication. Review of the resident #3's June 2023 MAR (Medication Administration Record) revealed no pain medication was administered. On 06/06/2023 at 10:45 a.m., S2DON (Director of Nursing) and S10Treatment RN (Registered Nurse) accompanied the surveyor to resident #3's room and evaluated the resident's bilateral lower extremities. S2DON and S10 Treatment RN both confirmed resident #3 had pain to bilateral lower extremities. An interview on 06/07/2023 at 11:03 a.m. with S5CNA (Certified Nurses Aide) revealed she had taken care of resident #3 and he had swelling and redness to bilateral lower extremities since he was admitted , but it comes and goes. S5CNA revealed resident #3 did have pain at times to both feet and she notified the nurses regarding swelling, redness, and pain, but she was unsure of the dates. Review of physician's order dated 06/06/2023 for resident #3 revealed an order for Tylenol Extra Strength oral tablet 500 mg (Milligrams) give 2 by mouth every 8 hours as needed for pain. Review of resident #3's nurses note dated 06/07/2023 at 10:00 a.m. revealed resident complaint of pain in right foot, states it's not so bad, 4/10 on pain scale, administered Tylenol Extra Strength 500 mg 2 tablets by mouth for pain. Review of the progress note for resident #3 dated 06/07/2023 at 12:34 p.m. revealed Tylenol Extra Strength oral tablet 500 mg give 2 tabs by mouth was administered for pain to right foot. An interview on 06/07/2023 at 1:50 p.m. with S9ADON revealed resident #3 was ordered Tylenol extra strength 500 mg 2 by mouth every 8 hours as needed for pain on 06/06/2023. S9ADON confirmed that Tylenol Extra Strength was not administered to resident #3 on 06/06/2023. An interview on 06/07/2023 at 2:20 p.m. with resident #3 confirmed he did not receive any pain medication 06/06/2023. Review of the June 2023 MAR revealed no documentation of Tylenol Extra Strength being administered on 06/06/2023 when resident #3 reported pain to S2DON and S10Treatment RN (Registered Nurse) while performing a body audit. An interview on 06/07/2023 at 3:02 p.m. with S2DON confirmed that resident #3 complained of pain to bilateral lower extremities on the morning of 06/06/2023 at 10:45 a.m. during a body audit. DON confirmed that resident #3 received an order for Tylenol Extra Strength beginning on 06/06/2023 but resident did not receive Tylenol until 06/07/2023 at 10:00 a.m. S2DON confirmed that Tylenol should have been administered on 06/06/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to obtain laboratory testing as ordered by the physician for 1 (#1) of 6 (#1, #2,#3,#4,#5,#6) residents investigated for laboratory services. Findings: Review of the medical record revealed resident #1 was admitted to the facility on [DATE] and discharged on 05/25/2023 with diagnoses of heart failure, hypertension, anemia, end stage renal disease, lack of coordination, muscle weakness, upper respiratory infection, and unsteadiness on the feet. Review of the admission Minimum Data Set, dated [DATE] revealed resident #1 had a BIMS (Brief Interview of Mental Status) score of 13 which indicated the resident is cognitively intact and needs limited assistance with activities of daily living. Further review revealed the resident is occasionally incontinent of bowel and bladder. Further review of the medical record revealed the following physician orders dated 05/11/2023: CBC (complete blood count) with auto differential, CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), and stool for XTAG (GI pathogen panel). Further review of the medical record revealed no documentation of the results of any of the labs ordered. An interview on 06/06/2023 at 2:30 p.m. with S2DON (Director of Nursing) confirmed the above orders for labs dated 05/11/2023 were not obtained as ordered.

Based on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate services to prevent complications by failing to properly clean and store syringes used for enteral use for 2 (#6, 31) of 2 (#6, 31) residents who were investigated for enteral feeding. Findings: Resident #6 Review of the physician orders revealed resident #6 received bolus feedings of Glucerna every 4 hours. On 11/14/2022 at 10:17 a.m. observation of the tube feeding supplies in the resident's room revealed the tube feeding syringe was stored at the bed side. There was a cloudy liquid in the tip of the syringe and the plunger was inside the syringe. This created an environment for the growth of bacteria. Resident #31 Review of the physician orders revealed resident #31 received a continuous enteral feeding of Glucerna. Observations on 11/14/2022 at 10:43 a.m. and on 11/15/2022 at 12:30 p.m. revealed the tube feeding syringe was stored at the bedside. Clear fluid was in the tip of the syringe and the plunger was inside the syringe. This created an environment for the growth of bacteria. On 11/16/2022 at 9:10 a.m. interview with #S2DON confirmed the syringes should be rinsed, disassembled and allowed to dry after each use.

Based on record review and interview the facility failed to obtain lab orders for 1 (#58) of 5 (#22, #51, #53, #58, #77) residents reviewed for unnecessary medication review. Findings: Review of the medical record for resident #58 revealed diagnoses of Diabetes Type 2, Hypertension, Anxiety Disorder, Iron Deficiency, and Vascular Dementia with behavioral disturbances. Review of the November 2022 Physician orders revealed resident #58 was taking levothyroxine 88mcg (micrograms) every morning, Metformin 1000mg (milligrams) by mouth twice a day, Tresiba 22 units subcutaneous at bedtime, Jardiance 25mg by mouth every day. On 11/15/2022 review of the Physician's orders dated 09/20/2022 revealed an order for CBC (Complete Blood Count), TSH (Thyroid Stimulating Hormone) and Hemoglobin A1C to be drawn now. Further review of the record revealed no documentation of the laboratory results for the CBC, TSH, and Hemoglobin A1C. On 11/16/22 at 10:58 a.m. interview with S5 LPN revealed she called the lab and the 09/20/2022 labs were not drawn as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #22 Resident #22 was admitted to the facility on [DATE] with diagnoses that include but not limited to the following: Alzheimer's disease with late onset, schizoaffective disorder depressive type, depression, and unspecified dementia without behavioral disturbance. Review of Resident #22's current November 2022 physician orders included the following psychotropic medications: Rexulti 1 mg (milligram) by mouth daily and Trintellix 10 mg by mouth daily. Review of the Consultant Pharmacy report dated 07/08/2022 revealed there was a recommendation for a dose reduction of Rexulti and Trintellix. The Physician signed the report on 07/12/2022 but failed to indicate if a dose reduction was or was not to be attempted. There was no documented rationale by the physician for continuing the medications. On 11/16/2022 at 10:08 a.m. an interview conducted with S2DON (Director of Nursing) confirmed that physician did not provide response with rationale to the Consultant Pharmacist recommendation. Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions unless clinically indicated for 2 (#22, 77) of 5 (#22, 51, 53, 58, 77) whose drug regimens were reviewed. The physician failed to provide a hand written clinical rationale for the declination of recommended dose reductions. Findings: Resident #77 Review of the physician orders for resident #77 revealed they received the psychotropic medications Risperidone, Buspar and Remeron. Review of the Consultant Pharmacy report dated 07/08/2022 revealed there was a recommendation for a dose reduction of Buspar, Remeron and Risperidone. The physician signed the report but failed to indicate if a dose reduction was or was not to be attempted. On 11/16/2022 at 9:45 a.m. interview with S2DON (Director of Nursing) confirmed the physician did not provide a response to the Consultant Pharmacists recommendation.