Based on record review and interview, the facility failed to ensure resident assessments were transmitted within the required timeframe for 1 (#100) of 1 (#100) residents investigated for assessments. Findings: Review of Resident #100's record revealed an admit date of 10/14/2021. Review of MDS (Minimum Data Set) Assessments in Resident 100's electronic medical record revealed annual assessments with assessment reference dates of 07/01/2024 were completed on 07/15/2024 with a status of Export Ready that had not been transmitted. During an interview on 08/06/2024 at 1:41 p.m., S5 MDS Nurse confirmed the 07/01/2024 assessments had been completed on 07/15/2024 and had not been transmitted.

Based on observations, interviews, and record reviews the facility failed to accommodate the needs of 4 (#9, #34, #106, #108) of 4 (#9, #34, #106, #108) residents reviewed for accommodation of needs out of a total sample of 31. The facility failed to ensure the resident's call light was within reach of the resident. Findings: Review of the facility's undated Fall Prevention Program Policy revealed in part: II: Preventive Protocol: A. admission Guidelines concerning fall: a. Prevention for High Risk residents: 2. Resident will be instructed regarding use of call bell by staff. Call bell will be placed within each resident's reach when feasible while in personal room. Resident will also be instructed to call for assistance when needed. Resident #9 Review of Resident #9's medical record revealed an admit date of 02/24/2017 with diagnoses that included lack of coordination, dementia without behavioral disturbances, presence of left artificial knee joint, and Alzheimer's disease with late onset. Review of Resident #9's care plan revealed Resident #9 was at high risk for falls, had a history of falls and required assistance to transfer. Observation on 08/05/2024 at 9:35 a.m. revealed Resident #9 sitting up in her wheelchair with her call light across the room, out of reach. Observation on 08/06/2024 at 9:30 p.m. revealed Resident #9 sitting in her recliner, call light hanging on the wall across the room, out of reach. Observation on 08/06/2024 1:30 p.m. revealed Resident #9 lying in bed, call light stretched behind the headboard to the recliner and in a closed drawer of the bedside table, out of reach. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN (Licensed Practical Nurse) revealed Resident #9's call light was out of reach. During interview on 08/06/2024 at 3:10 p.m. S4 LPN (Licensed Practical Nurse) confirmed Resident #9's call light was out of reach and should not have been. Resident #34 Review of Resident #34's medical record revealed an admit date of 06/15/2021 with diagnoses that included muscle wasting and atrophy, essential primary hypertension, lack of coordination, repeated falls, Alzheimer's disease, paroxysmal atrial fibrillation, and major depressive disorder severe with psychotic features. Review of Resident #34's care plan revealed Resident #34 was at high risk for falls, had a history of falls, and requires assistance to transfer. Observation on 08/05/2024 at 9:40 a.m. revealed Resident #34 sitting in her wheelchair near the head of her bed and the call light on the wall, near the foot of her bed, out of reach. Observation on 08/05/2024 at 2:30 p.m. revealed resident sitting up in wheelchair in her room near the head of the bed, call light remained against the wall at the foot of the bed out of reach. Observation on 08/06/2024 at 3:05 p.m. with S4 LPN (Licensed Practical Nurse) revealed Resident #34's call light was out of reach. During an interview on 08/06/2024 at 3:05 p.m. S4 LPN confirmed Resident #34's call light was out of reach and should not have been. Resident #106 Review of Resident #106's medical record revealed an admit date of 10/18/2022 with diagnoses that included muscle wasting and atrophy, contracture of left knee and ankle, left foot drop, contracture of right knee, primary generalized (Osteo) arthritis, other forms of scoliosis, major depressive disorder, and need for assistance with personal care. Review of Resident #106's care plan revealed Resident #106 was at high risk for falls, had a history of falls and requires assistance to transfer and uses a reclined Geri chair for locomotion. Observation on 08/06/2024 at 2:50 p.m. revealed Resident #106 sitting in reclined Geri Chair and Resident #34's call light was across the room, out of reach. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN revealed Resident #106 sitting in reclined Geri Chair and Resident #34's call light was out of reach. During an interview on 08/06/2024 at 3:30 p.m. S4 LPN confirmed Resident #106's call light was out of reach and should not have been. Resident #108 Review of Resident #108's medical record revealed an admit date of 03/25/2021 with diagnoses that included muscle wasting and atrophy, aphasia, repeated falls, Alzheimer's disease, paroxysmal atrial fibrillation, generalized anxiety disorder, syncope and collapse, and severe dementia with mood disturbance. Review of Resident #106's care plan revealed Resident #108 was at high risk for falls, had a history of falls and requires assistance to transfer. Observation on 08/05/2024 at 9:20 a.m. revealed Resident #108 sitting in her recliner and Resident #108's call light was across the room, out of reach. During an interview on 08/05/2024 at 9:20 a.m. Resident #108 reported she was not supposed to get up unless she called staff but she did not know where her button was. Observation on 08/06/2024 at 1:55 p.m. revealed Resident #108 lying in bed, with her call light stretched behind her headboard and over to her recliner, out of reach. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN revealed Resident #108 lying in bed, call light out of reach. During an interview on 08/06/2024 at 3:10 p.m. S4 LPN (Licensed Practical Nurse) confirmed Resident #108's call light was out of reach and should not have been. During an interview on 08/06/2024 at 3:30 p.m. S1 DON (Director of Nursing) acknowledged resident's call lights should be kept within reach at all times even if they don't remember to use it, they still have to have access to it.

Based on observations, interviews, and record reviews, the facility failed to provide residents' respiratory care and services in accordance with accepted professional standards of practice for 6 (#18, #23, #73, #57, #40, #290) out of 10 (#18, #23, #73, #57, #40, #290, #110, #35, #95, #51) residents reviewed for respiratory care. The facility failed to ensure: 1. Oxygen was administered at the ordered rate for Resident #40; 2. Oxygen tubing and humidification bottles were changed and dated weekly for Resident # 18, #23, #73, #57, and #290, and; 3. No Smoking signs were posted on the entrance to the rooms of residents on oxygen in accordance with facility policy for Resident #73. Findings: Review of the facility's Oxygen Administration (Concentrator or Tank) Policy (undated) revealed in part: While oxygen is in use, No Smoking signs will be posted at the entrance to the room . Humidifier bottles, cannulas and O2 (oxygen) tubing will be changed at least once weekly and dated .When not in use, cannula or mask should be placed in a plastic bag .Oxygen equipment, tanks, humidifier bottles, cannulas, masks and other related items should be checked on a regular basis during oxygen administration for proper functioning. Resident #18 Review of Resident #18's medical record revealed an admit date of 11/21/2022 with diagnoses including: persistent atrial fibrillation, pulmonary fibrosis, and essential primary hypertension. Review of Resident #18's physician orders revealed an order dated 11/21/2022 to change oxygen tubing/humidifier bottle and clean filter every week on Friday one time a day. Observation on 08/05/2024 at 8:05 a.m. revealed Resident #18 with oxygen in use at 2 L/min (liters /minute) via nasal cannula (NC). Further observation failed to reveal the oxygen tubing was dated when changed. Observation on 08/06/2024 at 3:00 p.m. revealed Resident #18 lying in bed with oxygen in use via NC, and oxygen tubing remained undated. Observation on 08/06/2024 at 3:30 p.m. with S1 DON (Director of Nursing) revealed Resident #18 oxygen tubing was undated. During an interview on 08/06/2024 at 3:30 p.m. S1 DON confirmed Resident #18's oxygen tubing had not been dated when changed and should have been. Resident #23 Review of Resident #23's medical record revealed an admit date of 03/22/2022 with diagnoses including: paroxysmal atrial fibrillation, dependence on supplemental oxygen, anxiety disorder, and chronic obstructive pulmonary disease. Review of Resident #23's physician orders revealed an order dated 07/01/2024 to change oxygen tubing/humidifier bottle and clean filter every week every Friday, night shift. Observation on 08/05/2024 at 8:20 a.m. revealed Resident #23's oxygen concentrator running at 2 L/min with oxygen tubing attached. Further observation failed to reveal the oxygen tubing was dated when changed. Observation on 08/06/2024 at 1:50 p.m. revealed Resident #23 with oxygen in use per NC. Further observation failed to reveal the oxygen tubing was dated when changed. Observation on 08/06/2024 at 3:10 p.m. with S4 LPN (Licensed Practical Nurse) revealed Resident #23 with oxygen in use via NC. Further observation failed to reveal the oxygen tubing had been dated when changed. During an interview on 08/06/2024 at 3:10 p.m., S4 LPN confirmed Resident #23's oxygen tubing was not dated with the date it was changed and it should have been. Resident #73 Review of Resident #73's record revealed an admit date of 09/08/2023 with diagnoses including: metabolic encephalopathy and acute upper respiratory infection unspecified. Further review revealed the resident was admitted to Hospice Services on 07/29/2024. Observation on 08/05/2024 at 9:05 a.m. revealed Resident #73 had oxygen in use at 2L/min via NC. Further observation revealed the humidification bottle and oxygen tubing were not dated when changed. Further observation revealed there was not a No Smoking sign on the entrance door to the room. Observation on 08/06/2024 at 3:02 p.m. revealed Resident #73 had oxygen in use at 2L/min via NC per oxygen concentrator. Further observation revealed the humidification bottle and oxygen tubing were not labeled with the date they had been changed. Further observation revealed there was not a No Smoking sign at the entrance to the room. Observation on 08/06/2024 at 3:55 p.m. with S2 RN (Registered Nurse)/Charge Nurse revealed Resident #73 had O2 in use via oxygen concentrator at 2L/min via NC. Further observation revealed the oxygen humidification bottle and oxygen tubing were not labeled with the date they had been changed, and there was not a No Smoking sign at the entrance to the room. During an interview on 08/06/2024 at 3:55 p.m. S2 RN/Charge Nurse confirmed Resident #73's oxygen humidification bottle and oxygen tubing were not dated with the date they were changed and they should be. S2 RN/Charge Nurse further confirmed there was not a No Smoking sign at the entrance to Resident #73's room and there should be. Resident #57 Review of Resident #57's record revealed an admit date of 05/31/2019 and diagnoses including: heart failure, shortness of breath, asthma, personal history of nicotine dependence, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and chronic obstructive pulmonary disease. Review of Resident #57's physician orders revealed an order dated 08/25/2023 to change oxygen tubing/humidifier bottle and clean filter every week on Friday. Observation on 08/05/2024 at 8:35 a.m. revealed Resident #57 was up in her wheelchair with O2 2L/min via NC in use via portable oxygen cylinder on the back of the wheelchair. The oxygen tubing was not labeled with the date it had been changed. Further observation revealed an oxygen concentrator next to the recliner in her room with humidification bottle dated 07/19/2024. The oxygen tubing attached to the concentrator was not labeled with the date it had been changed. Observation on 08/05/2024 at 11:55 a.m. revealed Resident #57 was up in her wheelchair with 2L/min via NC in use via portable oxygen tank on the back of the wheelchair. The oxygen cannula had no date indicating when it had been changed. Further observation revealed an oxygen concentrator next to the recliner in her room with humidification bottle dated 07/19/2024. The oxygen tubing attached to the concentrator was not labeled with the date it had been changed. Observation on 08/06/2024 at 3:55 p.m. with S2 RN/Charge Nurse revealed resident #57 was up in her wheelchair with oxygen in use per concentrator at 2L/min via NC with humidification bottle dated 08/06/2024. Further observation revealed the oxygen cannula attached to the concentrator was not labeled with the date it had been changed. Further observation revealed a portable oxygen tank on the back of Resident #57's wheelchair with oxygen tubing that was not labeled with the date it had been changed. During an interview on 08/06/2024 at 3:55 p.m., S2 RN/Charge Nurse confirmed Resident #57's oxygen tubings should both be labeled with the date they were changed and were not. Resident #40 Review of Resident #40's record revealed an admit date of 06/24/2024 with diagnoses including: heart failure, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic obstructive lung disease. Review of Resident #40's physician orders revealed an order dated 07/01/2024 for oxygen via 2L/min via NC continuous every shift related to chronic respiratory failure with hypoxia. During an observation and interview on 08/06/2024 at 2:17 p.m. Resident #40 was wearing oxygen tubing connected to an oxygen concentrator that was not turned on and was set at 0L/min. During an interview at this time, Resident #40 reported she wore the oxygen all the time. Resident #40 further reported she was a little short of breath. During an observation and interview on 08/06/2024 at 2:51 p.m., S3 LPN confirmed Resident #40's oxygen was turned off and should be on continuous at 2L/min. Resident #290 Review of Resident #290's record revealed an admit date of 07/19/2024 and diagnoses including: shortness of breath, dependence on supplemental oxygen, and chronic obstructive pulmonary disease. Review of Resident #290's physician orders revealed an order dated 07/19/2024 to change oxygen tubing, nasal cannula, humidifier bottle and clean filter one time a day every Friday. Observation on 08/05/2024 at 11:55 a.m. revealed Resident #290 had oxygen in use at 2L/min via NC per oxygen concentrator. Further observation revealed the humidifier bottle was not labeled with the date it had been changed. Observation on 08/06/2024 at 1:51 p.m. revealed resident #290 in the therapy gym in her wheelchair. Oxygen was in use via a portable oxygen tank at 2L/min via NC. Further observation revealed the oxygen tubing was not labeled with the date it had been changed. Observation on 08/06/2024 at 3:55 p.m. with S2 RN/Charge Nurse revealed Resident #290 had oxygen at 2L/min via NC in use via oxygen concentrator with a humidifier bottle that was not labeled with the date it had been changed. Further observation revealed a portable oxygen tank on the back of Resident #290's wheelchair with oxygen tubing that was not labeled with the date it had been changed. During an interview on 08/06/2024 at 3:55 p.m., S2 RN/Charge Nurse confirmed Resident #290's oxygen humidifier bottle and the oxygen tubing attached to the portable oxygen tank should be labeled with the date they had been changed and were not.

Based on observation and interviews, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and environment that promoted his or her quality of life. The facility failed to serve food at the same time to 1 Resident (#90) of 3 Residents (#47, #90, #119) sitting at the same table in the dining area. Findings: An observation on 08/14/23 at 12:10 p.m. revealed lunch trays served to Residents #47 and Resident #119. Resident #90 was sitting at the same table. Resident #90 did not get a lunch tray at that time. During an observation on 08/14/2023 at 12:24 p.m. Resident #47 and Resident #119 continued eating lunch at the same table with Resident #90. Resident #90 did not have her lunch tray and continued to watch Resident #47 and Resident #119 eat. Resident #47 spoke in an aggravated voice and pointed at Resident #90 saying, she needs help! Resident #90 was sitting at the table with her right hand raised up in the air. Resident #90's hand was moving slowing back and forth and looking around at staff as they passed out other lunch trays to other tables. During an observation on 08/14/2023 at 12:26 p.m. Resident #47 spoke out loud again saying she needs help and pointed to Resident #90 who continued to hold her hand in the air as she watched staff walk by with other residents' lunch trays. An observation on 08/14/2023 at 12:30 p.m. revealed Resident #90 was served her lunch tray and Resident #47 and Resident #119 were finished with their lunch. During an interview on 08/14/2023 at 12:30 p.m. S7 Licensed Practical Nurse acknowledged Resident #90 was served her lunch tray after Resident #47 and Resident #119 had already finished eating their meals. An observation on 08/14/2023 at 12:35 p.m. revealed Resident #90 was left eating her lunch by herself when Resident #47 and Resident #119 left the table. During an interview on 08/16/2023 at 2:25 p.m. S6 Dietary Manager reported residents should be served trays at the same time at each table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure 1 (#79) out of 5 (#19, #79, #116, #33, #70) sampled residents reviewed was free of unnecessary medications. The facility failed to monitor behaviors and side effects for Resident #79 while receiving an antidepresant and antipsychotic. Findings: Review of Resident #79's Medical Records revealed an admit date [DATE] with the following diagnoses, in part: Alzheimer's disease with late onset, dementia in other diseases classified elsewhere/mild/without behavioral disturbance/psychotic disturbance/mood disturbance and anxiety, and major depressive disorder/recurrent/severe with psychotic symptoms. Review of Resident #79's Care Plan revealed: - exhibits aggressive behavior with ADLs (activities of daily living) - monitor and document target behaviors - mood state/mood disorder related to diagnosis of major depression disorder - monitor patterns of target behavior - potential for adverse effects due to use of psychotropic medications - depression with psychotic features - monitor for behaviors and side effects Review of Resident #79's Physician's Orders revealed: 06/09/2023 - Depakote ER (extended release) 500mg (milligram) tablet extended release administer 1 tablet oral two times a day every day - major depressive disorder 04/13/2023 - Abilify 5 mg tablet administer 1 tablet oral one time a day - major depressive disorder Review of Resident #79's July and August MAR (Medication Administration Record) failed to reveal monitoring for antipsychotropic side effects and behaviors. During an interview on 08/16/2023 at 12:20 p.m. S3 LPN (licensed practical nurse) reported he documented behaviors and side effects in the notes when Resident #79 had them. S3 LPN was unable to tell surveyor why behaviors and side effects were not monitored daily on the MAR. During an interview on 08/16/2023 at 2:15 p.m. S2 ADON (assistant director of nursing) acknowledged Resident #79's care plan stated there should be monitoring of behaviors and side effects. S2 ADON acknowledged behaviors and side effects should have been monitored daily for Resident #79 and were not. During an interview on 08/16/2023 at 2:15 p.m. S1 DON (director of nursing) acknowledged behaviors and side effects should have been monitored daily for Resident #79 and were not.

Based on observations, interviews, and record review, the facility failed to ensure residents' food preferences were honored for 1 (#114) of 1 (#114) residents investigated for food preferences. Findings: Review of the facility's Nutrition Screening and Evaluation Report policy (Origination date 10/12, no Revised date) revealed in part: The Nutrition Screening and Evaluation Report (NSER) shall be completed by the dietary Manager on all new admissions, scheduled assessments, and quarterly progress .The dietary manager shall use the NSER to collect information necessary to begin meal service and for use in the assessment process. Upon admission, the dietary manager shall visit the new resident as soon as possible on the day of admission, preferably, and begin collecting information using the referenced form. Initial information shall be used to prepare the resident's tray card with food dislikes, preferences, allergies, etc. Review of Resident # 114's record revealed an admit date of 02/22/2022 and diagnoses including but not limited to: muscle wasting and atrophy, type 2 diabetes mellitus with diabetic polyneuropathy, unspecified protein-calorie malnutrition, irritable bowel syndrome, heart failure, and major depressive disorder. Review of Resident #114's August 2023 physician orders revealed an order dated 04/18/2022 for a Regular Diet with No Salt on Table (NSOT) and Low Concentrated Sweets (LCS). Review of Resident #114's most recently completed comprehensive MDS (Minimum Data Set) with an Assessment Reference Date of 07/19/2023 revealed a Brief Interview for Mental Status score of 15 out of 15 indicating the resident was cognitively intact. Review of Resident #114's resident nursing and dietary progress notes from 08/01/2022 to 08/15/2023 revealed no mention of the resident's preference for oatmeal at breakfast or her preference of a boiled egg at breakfast/dislike of powdered scrambled eggs. Review of Resident #114's Nutrition Screening Evaluations dated 09/14/2022, 09/14/2022, and 04/13/2023 revealed in part the resident received selective menu of choice, was able to make meal selection or request, and had no new dislikes or food preferences. During an observation and interview on 08/14/2023 at 8:50 a.m. Resident #114 complained of the food she was served at breakfast. Observation at this time revealed the resident's breakfast tray had a bowl of uneaten grits and uneaten scrambled eggs. Resident #114 reported I've told them I want oatmeal and a boiled egg with breakfast, and they keep bringing these powdered things that I won't eat. Resident #114 further reported she did not like grits, and was supposed to get oatmeal with breakfast. Further observation of Resident #114's meal slip on the breakfast tray revealed a note at the top of the slip oatmeal with breakfast. Further observation revealed S5 CNA (Certified Nursing Assistant) entered the room to pick up the tray. Resident #114 was observed telling S5 CNA she didn't like the facility's scrambled eggs and had asked over and over for a boiled egg with breakfast. S5 CNA told her we need to put that on your meal slip so the kitchen knows. Observation on 08/15/2023 at 8:18 a.m. revealed Resident #114's breakfast tray still had scrambled eggs instead of a boiled egg. The meal slip on Resident #114's breakfast tray still did not list her preference for a boiled egg with breakfast or a dislike of the facility's scrambled eggs. During an interview on 08/15/2023 at 4:25 p.m. S1 DON (Director of Nursing) reported the procedure for communicating a residents food requests, preferences, and dislikes would be for the CNAs to inform the nurses of the residents' requests. S1 DON reported the nurses should then fill out a dietary preference slip and send it to the dietary manager, who would add it to their meal slips used for preparing their trays. Observation on 08/16/2023 at 8:20 a.m. revealed Resident #114's breakfast tray had scrambled eggs instead of a boiled egg. The meal slip on Resident #114's breakfast tray did not list a request for boiled egg or a dislike of the facility's scrambled eggs. During an interview on 08/16/2023 at 8:20 a.m. S4 LPN (Licensed Practical Nurse) entered Resident #114's room and indicated he was not aware of Resident #114's dislike of scrambled eggs or her preference for a boiled egg at breakfast. During an interview on 08/16/2023 at 8:37 a.m. S6 Dietary Manager indicated staff use the meal slips when preparing trays, and were trained to substitute dislikes for likes, and to honor requests for specific items as possible and in accordance with any special dietary orders. S6 Dietary Manager further indicated sometimes the kitchen staff missed it, and the CNAs should catch it when serving the trays. S6 Dietary Manager indicated the CNAs should then come to the kitchen to obtain the residents' requested food items. S6 Dietary Manager further indicated she had not been aware of Resident #114's request for a boiled egg with breakfast until today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure resident assessments were transmitted to CMS (Centers for Medicare and Medicaid Services) within the required timeframe for 4 (#2, #3, #78, #92 ) residents of 9 (#2, #3, #4, #47, #55, #56, #77, #78, #92) residents reviewed for assessments out of a total of 44 sampled residents. Findings: Review of Resident #2's MDS (Minimum Data Set) assessments revealed a Quarterly MDS dated [DATE] with a status of open. Review of Resident #3's MDS (Minimum Data Set) assessments revealed a Quarterly MDS dated [DATE] with a status of open. Review of Resident #78's MDS (Minimum Data Set) assessments revealed a Quarterly MDS dated [DATE] with a status of open. Review of Resident #92's MDS (Minimum Data Set) assessments revealed a Yearly MDS dated [DATE] with a status of open. During an interview on 9/21/22 at 1:45pm S3, MDS Nurse confirmed MDS assessments for Resident #2, #3, #78, and #92 were not transmitted to CMS and should have been.

Based on record review and interview the facility failed to ensure an assessment was accurate for 1(#67) of 9 (#2, #3, #4, #47, #55, #56, #77, #78, #92) residents reviewed for assessments out of a total sample of 44. The facility failed to ensure an accurate MDS (Minimum data Set) assessment was entered for resident #67. Findings: Review of resident #67's current Physician's orders revealed an order dated 10/7/2021 for a Regular Diet/no salt on tray/LCS (Low Concentrated Sweets). Further review revealed an order dated 1/17/2022 for Two Cal House Supplement 120 cc (cubic centimeters) PO (by mouth) QID (4 times a day). Review of resident #67's Quarterly MDS with ARD (Assessment Reference Date) of 7/19/2022 revealed Section K - Swallowing/Nutritional Status. (K0300) Weight Loss 1. Yes on physician prescribed weight loss program. Review of resident #67's Comprehensive Plan of Care revealed a problem of potential for altered nutrition and dehydration related to hypertension, atrial fibrillation, GERD (Gastroesophageal reflux disease), deficiency of other vitamins. Goal is to maintain adequate nutritional status as evidence by maintaining stable weight. During an interview on 9/21/2022 at 1:45 pm S3 MDS Nurse reported she marked resident #67's MDS in error. S3 MDS Nurse reported she thought resident #67 was getting the dietary supplement to lose weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide appropriate care and services according to standards of professional practice for 1 (#33) of 2 (#33, #82) residents reviewed for urinary catheter or UTI (urinary tract infection) out of a total of 44 sampled residents. The facility failed to ensure urine color and condition was monitored for Resident #33 who had an indwelling (Foley) catheter in place. Findings: Review of Resident #33's medical record reveal Resident #33 was admitted to the facility on [DATE] and had diagnoses that included, in part, retention of urine, overactive bladder, urge incontinence, hydronephrosis, chronic kidney disease stage 2, Type 2 Diabetes Mellitus with diabetic nephropathy, essential hypertension, and metabolic encephalopathy. Review of Resident #33's current physician orders revealed: 9/16/2022 Monitor condition of urine Q (every) shift. 1=clear, 2=sediment, 3=mucous, 4=cloudy ****Call MD (Medical Doctor) if changes occur. 9/16/2022 Monitor color of urine Q shift 1=light yellow, 2=dark yellow, 3=amber, 4=bloody, 5=other ****call MD if changes occur. Review of September 2022 MAR (Medication Administration Record) failed to reveal evidence that urine color and condition of urine was monitored and documented every shift. Review of Progress notes revealed a 9/16/2022 note that indicated New order received per __________ NP (Nurse Practitioner) . Foley 16 fr (French)/30cc (cubic centimeters) placed. Review of Care Plan revealed: -Potential for UTI (Urinary Tract Infection) and/or complications r/t (related to) use of indwelling catheter d/t (due to) urinary retention with interventions that included, in part, monitor color of urine every shift and monitor condition of urine every shift. During an interview on 9/21/2022 at 3:50pm S2 DON (Director of Nursing) reported she had reviewed Resident #33's medical record and it did not include documentation of urine color and condition of urine for each shift and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident's drug regimen was free from unnecessary medications by failing to ensure gradual dose reduction for psychotropic medications was conducted for 1 (#72) of 5 ( #7, #45, #48, #72, #230) residents reviewed for unnecessary medications. Findings: Review of Resident #72's medical record revealed Resident #72 was admitted to the facility on [DATE] and had diagnoses that included, in part, major depressive disorder recurrent severe with psychotic symptoms, dementia, generalized anxiety disorder, essential hypertension, atherosclerotic heart disease, and hypertensive chronic kidney disease. Review of current physician orders revealed the following orders: 1/28/2022 - Abilify 2 mg (milligram) tablet, give 1 tab PO (by mouth) Q (every) day 11/16/2021 - Buspirone HCL (hydrochloride) 5mg tablet, give 1 tab PO BID (two times a day) Review of medical record failed to reveal any GDR (Gradual Dose Reduction) pharmacy request had been conducted in regard to Resident #72's Abilify and Buspirone. During an interview on 9/21/2022 at 3:45pm S2 DON (Director of Nursing) and S4 Corporate Nurse reported the facility did not have any GDR pharmacy request for Resident #72's Abilify and Buspirone and should have.